MEDICARE: AUBREY LEE BROCK RBT

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	BACB1350369	IL

General Provider Information

NPI Number	:	1417846122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUBREY LEE BROCK RBT

Provider Business Mailing Address
First Line	:	919 SOUTHWIND CT
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-1544
Country	:	US
Telephone Number	:	618-698-4366
Fax Number	:

Provider Business Practice Location Address
First Line	:	2421 CORPORATE CTR STE 100
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4195
Country	:	US
Telephone Number	:	618-698-4366
Fax Number	:

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

Provider Enumeration Date	:	06/30/2025
Last Update Date	:	06/30/2025

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