Provider Demographics
NPI:1184050247
Name:GIBLOCK, BRENNA
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:GIBLOCK
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 1:1673 MASON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5516
Mailing Address - Country:US
Mailing Address - Phone:386-451-8208
Mailing Address - Fax:
Practice Address - Street 1:1673 MASON AVE STE 100
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5516
Practice Address - Country:US
Practice Address - Phone:386-873-0365
Practice Address - Fax:386-873-0366
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-20
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker