MEDICARE: LISA BROCK COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1053876227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA BROCK COUNSELING

Provider Business Mailing Address
First Line	:	8600 GATEHOUSE WAY
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-6022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4943 OLD GREENWOOD RD STE 9
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-6923
Country	:	US
Telephone Number	:	479-461-7789
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MRS. LISA BROCK
Credential	:	LPC LMFT
Telephone Number	:	479-461-7789

Provider Enumeration Date	:	02/01/2019
Last Update Date	:	02/01/2019

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