Healthcare Provider Details

I. General information

NPI: 1003736414
Provider Name (Legal Business Name): BROCK ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 E CHANDLER BLVD STE 235
PHOENIX AZ
85048-7689
US

IV. Provider business mailing address

4505 E CHANDLER BLVD STE 235
PHOENIX AZ
85048-7689
US

V. Phone/Fax

Practice location:
  • Phone: 480-447-6443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLAMFT-10913
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: