MEDICARE: BROCK BARBOSA AMFT

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	106H00000X	Marriage & Family Therapist	AMFT135969	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AMFT135969	OTHER	CA	CALIFORNIA BOARD OF BEHAVIORAL SCIENCES

General Provider Information

NPI Number	:	1609585330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROCK BARBOSA AMFT

Provider Business Mailing Address
First Line	:	201 E CENTER ST STE 112-3221
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92805-7204
Country	:	US
Telephone Number	:	747-254-6290
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 E CENTER ST STE 112-3221
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92805-7204
Country	:	US
Telephone Number	:	747-254-6290
Fax Number	:

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

Provider Enumeration Date	:	11/21/2022
Last Update Date	:	07/16/2025

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