Healthcare Provider Details

I. General information

NPI: 1780949883
Provider Name (Legal Business Name): KRISTIN M. BROCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E GRAND AVE
PONCA CITY OK
74601-5205
US

IV. Provider business mailing address

212 N MAIN ST
FAIRFAX OK
74637-3023
US

V. Phone/Fax

Practice location:
  • Phone: 580-302-8270
  • Fax: 580-749-5682
Mailing address:
  • Phone: 918-642-3100
  • Fax: 918-642-5639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3832
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: