Healthcare Provider Details

I. General information

NPI: 1144028606
Provider Name (Legal Business Name): BRANDY LYNN BROCK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7005 RIDGE WAY
GAINESVILLE GA
30506-7059
US

IV. Provider business mailing address

7005 RIDGE WAY
GAINESVILLE GA
30506-7059
US

V. Phone/Fax

Practice location:
  • Phone: 912-996-4564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC016349
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: