MEDICARE: DIAMOND E 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		MS

General Provider Information

NPI Number	:	1841145703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIAMOND E BROCK

Provider Business Mailing Address
First Line	:	14912 MALLETT RD APT A204
Second Line	:
City	:	BILOXI
State	:	MS
Zip	:	39532-0003
Country	:	US
Telephone Number	:	205-471-6979
Fax Number	:

Provider Business Practice Location Address
First Line	:	1043 PASS RD.
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501
Country	:	US
Telephone Number	:	205-471-6979
Fax Number	:

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

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	03/04/2026

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Directions to “ DIAMOND E BROCK ” Practice Location

Language	Start Address	Practice Location

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