MEDICARE: MARY ANN BROCK MFT

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	101YM0800X	Mental Health Counselor	MFC28293	CA

General Provider Information

NPI Number	:	1518493675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ANN BROCK MFT

Provider Business Mailing Address
First Line	:	825 OAK GROVE AVE
Second Line	:	D202
City	:	MENLO PARK
State	:	CA
Zip	:	94025-4434
Country	:	US
Telephone Number	:	650-380-9132
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 OAK GROVE AVE
Second Line	:	D202
City	:	MENLO PARK
State	:	CA
Zip	:	94025-4434
Country	:	US
Telephone Number	:	650-380-9132
Fax Number	:

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

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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