Basic Information
| Provider Information | |||||||||
| NPI: | 1386176592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | CHARLOTTE | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3953 WEBER WAY | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405141009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592021316 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 CHESTNUT STATION CT | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402996395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003351060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2017 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 170593 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.