Provider Demographics
NPI:1336161520
Name:BROCK, WILLIAM DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DAVID
Last Name:BROCK
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 1:1241 MALL DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4737
Mailing Address - Country:US
Mailing Address - Phone:804-794-8828
Mailing Address - Fax:804-794-4735
Practice Address - Street 1:1241 MALL DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-4737
Practice Address - Country:US
Practice Address - Phone:804-794-8828
Practice Address - Fax:804-794-4735
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1399103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7755163Medicaid
O39287OtherANTHEM PROVIDER NUMBER