Provider Demographics
NPI:1861249427
Name:BROCK, MADISON LEEANN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:LEEANN
Last Name:BROCK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 ELWYNNE DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-4019
Mailing Address - Country:US
Mailing Address - Phone:937-694-2553
Mailing Address - Fax:
Practice Address - Street 1:767 LOVELAND MIAMIVILLE RD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-0018
Practice Address - Country:US
Practice Address - Phone:513-774-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.14096235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist