MEDICARE: MARY JOSEPHINE 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	106S00000X	Behavior Technician		LA

General Provider Information

NPI Number	:	1174473722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JOSEPHINE BROCK

Provider Business Mailing Address
First Line	:	350 FAIRWAY DR STE 101
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33441-1834
Country	:	US
Telephone Number	:	877-418-2978
Fax Number	:	866-500-2186

Provider Business Practice Location Address
First Line	:	4202 N I-10 SERVICE RD W.
Second Line	:
City	:	METAIRIE
State	:	LA
Zip	:	70006
Country	:	US
Telephone Number	:	504-641-4319
Fax Number	:

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

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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Directions to “ MARY JOSEPHINE BROCK ” Practice Location

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