Healthcare Provider Details

I. General information

NPI: 1679041636
Provider Name (Legal Business Name): MELISSA MARIE BROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA MARIE AMMERMAN

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 S NEW HAMPSHIRE AVE
LOS ANGELES CA
90005-1355
US

IV. Provider business mailing address

1931 ERIN AVE
UPLAND CA
91784-1545
US

V. Phone/Fax

Practice location:
  • Phone: 626-254-5000
  • Fax:
Mailing address:
  • Phone: 909-771-8852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number41003
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: