Provider Demographics
NPI:1912622234
Name:BROCK, DAVID E (RADT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:BROCK
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 DAHLIA AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2102
Mailing Address - Country:US
Mailing Address - Phone:949-694-7172
Mailing Address - Fax:
Practice Address - Street 1:601 DAHLIA AVE
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2102
Practice Address - Country:US
Practice Address - Phone:951-259-3122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician