Provider Demographics
NPI:1902580343
Name:BROCK, DARREN
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 E WASHINGTON ST APT 1313
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4672
Mailing Address - Country:US
Mailing Address - Phone:909-379-2550
Mailing Address - Fax:
Practice Address - Street 1:1699 E WASHINGTON ST APT 1313
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4672
Practice Address - Country:US
Practice Address - Phone:909-379-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician