Provider Demographics
NPI:1740351121
Name:BROCK, MICHAEL (LICSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HAVILAND ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-2683
Mailing Address - Country:US
Mailing Address - Phone:617-267-0900
Mailing Address - Fax:617-267-3667
Practice Address - Street 1:7 HAVILAND ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-2683
Practice Address - Country:US
Practice Address - Phone:617-267-0900
Practice Address - Fax:617-267-3667
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA107584101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303546Medicaid
MAY101387Medicare ID - Type UnspecifiedMEDICARE B
MA1303546Medicaid