Healthcare Provider Details

I. General information

NPI: 1609425602
Provider Name (Legal Business Name): AARON THOMAS BROCKIE MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10257 STATE ROUTE 3
RED BUD IL
62278-4418
US

IV. Provider business mailing address

10257 STATE ROUTE 3
RED BUD IL
62278-4418
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-6233
  • Fax: 888-388-1971
Mailing address:
  • Phone: 618-282-6233
  • Fax: 888-388-1971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178022415
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: