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General NPI Number Information
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NPI Number | 1679041636
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Entity Type | Individual
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Provider Name | MELISSA MARIE BROCK
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Gender | Female
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Dates
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Enumeration Date | 11/08/2018
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Last Update Date | 11/08/2018
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Provider Practice Location Address
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Address Line | 679 S NEW HAMPSHIRE AVE
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City | LOS ANGELES
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State | CA
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Zip | 90005-1355
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Country | US
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Telephone | 626-254-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 1931 ERIN AVE
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City | UPLAND
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State | CA
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Zip | 91784-1545
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Country | US
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Telephone | 909-771-8852
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 167G00000X
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Taxonomy Name | Licensed Psychiatric Technician
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License Number | 41003
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License Number State | CA
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