Healthcare Provider Details

I. General information

NPI: 1053190819
Provider Name (Legal Business Name): BRYAN DUBROCK LCSW-21781
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 W ROYAL PALM RD
PHOENIX AZ
85021-4924
US

IV. Provider business mailing address

2700 N CENTRAL AVE STE 1050
PHOENIX AZ
85004-1217
US

V. Phone/Fax

Practice location:
  • Phone: 602-269-5300
  • Fax:
Mailing address:
  • Phone: 602-266-8402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-21781
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: