Healthcare Provider Details

I. General information

NPI: 1962730606
Provider Name (Legal Business Name): MARIA TONITA BROCK L.I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CARDENAS DR SE
ALBUQUERQUE NM
87108-4809
US

IV. Provider business mailing address

1121 IRON AVE SW
ALBUQUERQUE NM
87102-3753
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-0992
  • Fax:
Mailing address:
  • Phone: 505-908-0015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05878
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCADS-012
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: