Healthcare Provider Details

I. General information

NPI: 1104759299
Provider Name (Legal Business Name): BROCK OWEN MELANCON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 GOVERNMENT ST
BATON ROUGE LA
70802-4802
US

IV. Provider business mailing address

1120 GOVERNMENT ST
BATON ROUGE LA
70802-4802
US

V. Phone/Fax

Practice location:
  • Phone: 225-888-5810
  • Fax: 225-256-4210
Mailing address:
  • Phone: 225-888-5810
  • Fax: 225-256-4210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: