=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326497173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR LAURA BROCK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2016
-----------------------------------------------------
Last Update Date | 06/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 W DRUMMOND PL APT 418
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-212-4222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 W DRUMMOND PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. LAURA BROCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-212-4221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 071008718
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------