Healthcare Provider Details

I. General information

NPI: 1932513249
Provider Name (Legal Business Name): YVONNE BROCK CAC-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 W ST NE
WASHINGTON DC
20018-3503
US

IV. Provider business mailing address

1308 W ST NE
WASHINGTON DC
20018-3503
US

V. Phone/Fax

Practice location:
  • Phone: 301-821-3805
  • Fax:
Mailing address:
  • Phone: 301-821-3805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACO340
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberAC0340
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License NumberACO340
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberACO340
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License NumberACO340
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: