Provider Demographics
NPI:1023414331
Name:BROCK, ROBERT TRAVIS (MS, LMHP, PLADC, LPC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:TRAVIS
Last Name:BROCK
Suffix:
Gender:M
Credentials:MS, LMHP, PLADC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6249 PONDEROSA CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-4277
Mailing Address - Country:US
Mailing Address - Phone:402-895-1747
Mailing Address - Fax:402-599-2564
Practice Address - Street 1:1709 JACKSON ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-2513
Practice Address - Country:US
Practice Address - Phone:402-599-2550
Practice Address - Fax:402-599-2565
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1258101YA0400X
NE4384101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)