Healthcare Provider Details

I. General information

NPI: 1477166320
Provider Name (Legal Business Name): RITA ELAINE BROCKIE MS ED, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2419 E 3RD ST
MISHAWAKA IN
46544-3327
US

IV. Provider business mailing address

2419 E 3RD ST
MISHAWAKA IN
46544-3327
US

V. Phone/Fax

Practice location:
  • Phone: 574-309-5229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: