Provider Demographics
NPI:1932435435
Name:BROCK, MELISSA (LSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 RUSSET LN
Mailing Address - Street 2:APT H
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-9065
Mailing Address - Country:US
Mailing Address - Phone:513-227-4137
Mailing Address - Fax:
Practice Address - Street 1:1490 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-3305
Practice Address - Country:US
Practice Address - Phone:513-896-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0900538104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker