Provider Demographics
NPI:1811556244
Name:BROCK, KENNEDY M (CDCA)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:M
Last Name:BROCK
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E DUBLIN GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3192
Mailing Address - Country:US
Mailing Address - Phone:614-844-3800
Mailing Address - Fax:
Practice Address - Street 1:22 N 1ST ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5608
Practice Address - Country:US
Practice Address - Phone:740-326-9099
Practice Address - Fax:740-326-9099
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.169575101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)