Provider Demographics
NPI:1821143272
Name:BROCK, KATHLEEN J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:J
Last Name:BROCK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
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Mailing Address - Street 1:1201 BROOKINGS DR
Mailing Address - Street 2:C B 1201
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130
Mailing Address - Country:US
Mailing Address - Phone:314-935-6666
Mailing Address - Fax:314-935-5781
Practice Address - Street 1:1 BROOKINGS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-4862
Practice Address - Country:US
Practice Address - Phone:314-935-6666
Practice Address - Fax:314-935-8515
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006029891103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical