Provider Demographics
NPI:1669129649
Name:BROCK, LISA BETH
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
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 1:1320 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-4212
Mailing Address - Country:US
Mailing Address - Phone:469-667-9007
Mailing Address - Fax:
Practice Address - Street 1:1320 IRIS LN
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4212
Practice Address - Country:US
Practice Address - Phone:469-667-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date: