Provider Demographics
NPI:1861634339
Name:BROCK, ANN GWENDOLYN (OTR)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:GWENDOLYN
Last Name:BROCK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13220 TUSCOLA RD
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-1832
Mailing Address - Country:US
Mailing Address - Phone:989-295-6928
Mailing Address - Fax:
Practice Address - Street 1:13220 TUSCOLA RD
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-1832
Practice Address - Country:US
Practice Address - Phone:989-295-6928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1329297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist