Provider Demographics
NPI:1548361744
Name:BROCK, WILLIAM MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:BROCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 ADAMS AVE
Mailing Address - Street 2:A174
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2490
Mailing Address - Country:US
Mailing Address - Phone:619-665-2125
Mailing Address - Fax:619-528-8350
Practice Address - Street 1:3435 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 205
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3902
Practice Address - Country:US
Practice Address - Phone:619-665-2125
Practice Address - Fax:619-528-8350
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8466103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY084660Medicaid
CACP8466Medicaid
CACP8466AMedicare ID - Type UnspecifiedMEDICARE