Provider Demographics
NPI:1851058952
Name:BROCK, KATHRYN M (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:BROCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:M
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4116 SKYLINE LOOP NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-1609
Mailing Address - Country:US
Mailing Address - Phone:817-729-9099
Mailing Address - Fax:
Practice Address - Street 1:4116 SKYLINE LOOP NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-1609
Practice Address - Country:US
Practice Address - Phone:817-729-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-11496261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health