Provider Demographics
NPI:1144862780
Name:SCHLUDECKER, BROCK J
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:J
Last Name:SCHLUDECKER
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 1:120 TIBET RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1436
Mailing Address - Country:US
Mailing Address - Phone:330-464-5573
Mailing Address - Fax:
Practice Address - Street 1:6631 COMMERCE PKWY STE R
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3239
Practice Address - Country:US
Practice Address - Phone:614-360-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7853103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)