=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578926259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID B BROCK OTR/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2016
-----------------------------------------------------
Last Update Date | 03/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 N MAIN AVE
-----------------------------------------------------
City | SCRANTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18504-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-341-5012
-----------------------------------------------------
Fax | 570-341-5092
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 ELECTRIC ST
-----------------------------------------------------
City | CLARKS SUMMIT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18411-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-586-4183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OC004240L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------