Healthcare Provider Details

I. General information

NPI: 1508439324
Provider Name (Legal Business Name): MARYANN BROCK AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 DEL PRADO BLVD S # 100
CAPE CORAL FL
33990-3601
US

IV. Provider business mailing address

24 HEATHWOOD RD
WILLIAMSVILLE NY
14221-4616
US

V. Phone/Fax

Practice location:
  • Phone: 239-574-4600
  • Fax:
Mailing address:
  • Phone: 716-250-3083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY2856
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: