Provider Demographics
NPI:1821423807
Name:BROCK, TEKEISHA NICOLE
Entity Type:Individual
Prefix:
First Name:TEKEISHA
Middle Name:NICOLE
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1487 W KEISER AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72370-2806
Mailing Address - Country:US
Mailing Address - Phone:870-563-4500
Mailing Address - Fax:870-563-4501
Practice Address - Street 1:1487 W KEISER AVE STE 1
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-2806
Practice Address - Country:US
Practice Address - Phone:870-563-4500
Practice Address - Fax:870-563-4501
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator