Provider Demographics
NPI:1295005635
Name:BROCK, TONYA RENEE (BSW, DS)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:RENEE
Last Name:BROCK
Suffix:
Gender:F
Credentials:BSW, DS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 SHIPLEY WAY SW
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-6089
Mailing Address - Country:US
Mailing Address - Phone:304-590-2459
Mailing Address - Fax:
Practice Address - Street 1:816 SHIPLEY WAY SW
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-6089
Practice Address - Country:US
Practice Address - Phone:304-590-2459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-02
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV252Y00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist