Provider Demographics
NPI:1952730194
Name:BROCK, ASHA (MFT)
Entity Type:Individual
Prefix:MS
First Name:ASHA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1034
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-1034
Mailing Address - Country:US
Mailing Address - Phone:209-481-3924
Mailing Address - Fax:209-754-3626
Practice Address - Street 1:593 WEST SAINT CHARLES STREET
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-481-3924
Practice Address - Fax:209-754-3626
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40717106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist