Provider Demographics
NPI:1538563200
Name:BROCK, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 OLD BOONTON RD
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-2055
Mailing Address - Country:US
Mailing Address - Phone:203-913-5168
Mailing Address - Fax:
Practice Address - Street 1:159 W 127TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3723
Practice Address - Country:US
Practice Address - Phone:203-913-5168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019139225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist