Healthcare Provider Details

I. General information

NPI: 1821926916
Provider Name (Legal Business Name): BROCK LUBBERS PEER SUPPORT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

4977 NORTHCUTT PL
DAYTON OH
45414-3839
US

IV. Provider business mailing address

9 S WESTERN AVE
SPRINGFIELD OH
45506-1339
US

V. Phone/Fax

Practice location:
  • Phone: 800-829-5461
  • Fax:
Mailing address:
  • Phone: 937-206-8498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number007394
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: