Provider Demographics
NPI:1174287775
Name:BROCK, ANGELA C (MEDCCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:C
Last Name:BROCK
Suffix:
Gender:F
Credentials:MEDCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5563 SUMMIT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601
Mailing Address - Country:US
Mailing Address - Phone:912-381-7391
Mailing Address - Fax:
Practice Address - Street 1:10547 PEPPERGRASS CT
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-5045
Practice Address - Country:US
Practice Address - Phone:727-222-3762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8713235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist