Provider Demographics
NPI:1750009221
Name:BROCK, NICHOLAS RYAN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:BROCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 CUMBERLAND CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-8289
Mailing Address - Country:US
Mailing Address - Phone:859-652-5896
Mailing Address - Fax:
Practice Address - Street 1:3322 RANCH ROAD 620 S
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-6804
Practice Address - Country:US
Practice Address - Phone:512-533-6000
Practice Address - Fax:512-533-6001
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120170235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist