Provider Demographics
NPI:1962626911
Name:BROCK, MARCIA HUDGINS
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:HUDGINS
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 1:729 RIDGECREST RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2147
Mailing Address - Country:US
Mailing Address - Phone:706-884-5246
Mailing Address - Fax:706-443-1303
Practice Address - Street 1:729 RIDGECREST RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2147
Practice Address - Country:US
Practice Address - Phone:706-884-5246
Practice Address - Fax:706-443-1303
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003680235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist