MEDICARE: BRIDGETT ANN BROCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1013434745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIDGETT ANN BROCK

Provider Business Mailing Address
First Line	:	1262 SUNFLOWER CIR N
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-1791
Country	:	US
Telephone Number	:	951-570-6440
Fax Number	:

Provider Business Practice Location Address
First Line	:	1262 SUNFLOWER CIR N
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-1791
Country	:	US
Telephone Number	:	951-570-6440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	08/23/2017

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