Provider Demographics
NPI:1447986724
Name:BROCK, ADRIANA LEE (AMFT)
Entity type:Individual
Prefix:
First Name:ADRIANA
Middle Name:LEE
Last Name:BROCK
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AMFT
Mailing Address - Street 1:333 MILLER AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2894
Mailing Address - Country:US
Mailing Address - Phone:415-690-9668
Mailing Address - Fax:
Practice Address - Street 1:333 MILLER AVE STE 2
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2894
Practice Address - Country:US
Practice Address - Phone:415-690-9668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT136434106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist