Healthcare Provider Details

I. General information

NPI: 1265396360
Provider Name (Legal Business Name): ANDREA BROCKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4722 OXBOTTOM DR
VALDOSTA GA
31605-6379
US

IV. Provider business mailing address

4722 OXBOTTOM DR
VALDOSTA GA
31605-6379
US

V. Phone/Fax

Practice location:
  • Phone: 229-415-4416
  • Fax:
Mailing address:
  • Phone: 229-415-4416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS020616
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: