Provider Demographics
NPI:1811556244
Name:BROCK, KENNEDY M (LSW)
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:M
Last Name:BROCK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W GAMBIER ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-2421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 W GAMBIER ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-2421
Practice Address - Country:US
Practice Address - Phone:740-326-9099
Practice Address - Fax:740-326-9099
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.169575101YA0400X
171M00000X
OHS.2512279104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator