Healthcare Provider Details

I. General information

NPI: 1629478946
Provider Name (Legal Business Name): LISA G BROCK MS, LPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2014
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 S WALDRON RD
FORT SMITH AR
72903-3088
US

IV. Provider business mailing address

8600 GATEHOUSE WAY
FORT SMITH AR
72916-6022
US

V. Phone/Fax

Practice location:
  • Phone: 479-242-7111
  • Fax:
Mailing address:
  • Phone: 479-461-7789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1808107
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM1807017
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: