Provider Demographics
NPI:1962835967
Name:BROCK, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
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 1:421 FALLSWAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4800
Mailing Address - Country:US
Mailing Address - Phone:410-837-5533
Mailing Address - Fax:
Practice Address - Street 1:421 FALLSWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4800
Practice Address - Country:US
Practice Address - Phone:410-837-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17054104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker