Provider Demographics
NPI:1952383077
Name:BROCK, DENIESE EARLENE (PT)
Entity Type:Individual
Prefix:MS
First Name:DENIESE
Middle Name:EARLENE
Last Name:BROCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7403 BRIXWORTH CT UNIT 101
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-5670
Mailing Address - Country:US
Mailing Address - Phone:302-750-1785
Mailing Address - Fax:443-316-8641
Practice Address - Street 1:2225 OLD EMMORTON RD STE 210
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-6123
Practice Address - Country:US
Practice Address - Phone:410-569-0990
Practice Address - Fax:410-515-0777
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000041626Medicaid
DE084500Medicare ID - Type Unspecified