Healthcare Provider Details

I. General information

NPI: 1801585914
Provider Name (Legal Business Name): HAILEY BROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 SAINT ANDREWS BLVD
PANAMA CITY FL
32405-2167
US

IV. Provider business mailing address

4750 COLLEGIATE DR
PANAMA CITY FL
32405-1000
US

V. Phone/Fax

Practice location:
  • Phone: 850-818-0095
  • Fax: 850-481-1448
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2828574
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: