Healthcare Provider Details

I. General information

NPI: 1740948868
Provider Name (Legal Business Name): SAMANTHA BROCK MSW, APSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10045 W LISBON AVE
WAUWATOSA WI
53222-2446
US

IV. Provider business mailing address

5225 N 65TH ST
MILWAUKEE WI
53218-3009
US

V. Phone/Fax

Practice location:
  • Phone: 414-358-7144
  • Fax:
Mailing address:
  • Phone: 414-587-5162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131898121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: