Provider Demographics
NPI:1982627345
Name:MCKAY, BROCK L (PHD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:L
Last Name:MCKAY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7807 E FUNSTON ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-3123
Mailing Address - Country:US
Mailing Address - Phone:316-636-1188
Mailing Address - Fax:316-636-1190
Practice Address - Street 1:7807 E FUNSTON ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-3123
Practice Address - Country:US
Practice Address - Phone:316-636-1188
Practice Address - Fax:316-636-1190
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0904103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4589OtherPREFERRED HEALTH SYSTEMS
KS63173OtherPREMIERE BLUE ID
KS119800OtherBCBS PROVIDER NUMBER