Provider Demographics
NPI:1336337112
Name:BROCK, TIFFANY D
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:D
Last Name:BROCK
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 1:65 OLD SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-9185
Mailing Address - Country:US
Mailing Address - Phone:270-692-2509
Mailing Address - Fax:270-692-2592
Practice Address - Street 1:65 OLD SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-9185
Practice Address - Country:US
Practice Address - Phone:270-692-2509
Practice Address - Fax:270-692-2592
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1052101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional