MEDICARE: DR. WILLIAM MICHAEL BROCK PH.D.

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	103T00000X	Psychologist	PSY8466	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548361744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM MICHAEL BROCK PH.D.

Provider Business Mailing Address
First Line	:	3401 ADAMS AVE
Second Line	:	A174
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-2490
Country	:	US
Telephone Number	:	619-665-2125
Fax Number	:	619-528-8350

Provider Business Practice Location Address
First Line	:	3435 CAMINO DEL RIO S
Second Line	:	SUITE 205
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3902
Country	:	US
Telephone Number	:	619-665-2125
Fax Number	:	619-528-8350

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2007

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Directions to “ DR. WILLIAM MICHAEL BROCK PH.D.” Practice Location

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