Provider Demographics
NPI:1689457442
Name:BROCK, ANNE MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:MARIE
Last Name:BROCK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 4TH RD
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-9078
Mailing Address - Country:US
Mailing Address - Phone:574-274-5468
Mailing Address - Fax:
Practice Address - Street 1:282 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-2558
Practice Address - Country:US
Practice Address - Phone:574-501-5342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004590A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist