Provider Demographics
NPI:1245697069
Name:BROCK, CHARLES (JURIST DOCTOR)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:JURIST DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 PEAR TREE CIR
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-7240
Mailing Address - Country:US
Mailing Address - Phone:337-419-6227
Mailing Address - Fax:
Practice Address - Street 1:8706 JEFFERSON HWY STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2233
Practice Address - Country:US
Practice Address - Phone:225-926-9706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health