Provider Demographics
NPI:1760890321
Name:BROCK, HUBERT CHARLES II (MA)
Entity Type:Individual
Prefix:MR
First Name:HUBERT
Middle Name:CHARLES
Last Name:BROCK
Suffix:II
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15388 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-2825
Mailing Address - Country:US
Mailing Address - Phone:626-893-2010
Mailing Address - Fax:
Practice Address - Street 1:11951 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1855
Practice Address - Country:US
Practice Address - Phone:760-956-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79973106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist