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General NPI Number Information
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NPI Number | 1609250992
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Entity Type | Organization
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Legal Business Name | BROCK FAMILY THERAPY CENTER INC.
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Dates
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Enumeration Date | 07/16/2015
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Last Update Date | 08/21/2023
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Provider Practice Location Address
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Address Line | 10300 BROOKRIDGE VILLAGE BLVD SUITE 104
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City | LOUISVILLE
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State | KY
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Zip | 40291
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Country | US
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Telephone | 502-785-4322
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Fax | 502-785-4433
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Provider Business Mailing Address
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Address Line | 10300 BROOKRIDGE VILLAGE BLVD SUITE 104
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City | LOUISVILLE
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State | KY
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Zip | 40291
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Country | US
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Telephone | 502-785-4322
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Fax | 502-785-4433
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Authorized Official
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Title or Position | PRINCIPAL THERAPIST/OWNER
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Name | MRS. ANGELA C BROCK
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Credential | LCSW, LMFT, MBA
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Telephone | 502-785-4322
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 3035
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 0617
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License Number State | KY
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