Provider Demographics
NPI:1174069769
Name:BROCK, MARY ARMINDA
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ARMINDA
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 1:4400 WEST MAIN ST.#116
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072
Mailing Address - Country:US
Mailing Address - Phone:405-468-7933
Mailing Address - Fax:
Practice Address - Street 1:4400 W MAIN ST TRLR 116
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4302
Practice Address - Country:US
Practice Address - Phone:405-468-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician