Provider Demographics
NPI:1255563490
Name:BROCK, PETER (MSED, ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:MSED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 WESLEYAN ST
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-1536
Mailing Address - Country:US
Mailing Address - Phone:817-531-7590
Mailing Address - Fax:
Practice Address - Street 1:1201 WESLEYAN STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-1215
Practice Address - Country:US
Practice Address - Phone:817-531-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT44982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer