Healthcare Provider Details

I. General information

NPI: 1396299764
Provider Name (Legal Business Name): BROCK SEEFELDT C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CUNNINGHAM WAY BUILDING 1
DANVILLE KY
40422-8339
US

IV. Provider business mailing address

1600 W 22ND ST
SIOUX FALLS SD
57105-1521
US

V. Phone/Fax

Practice location:
  • Phone: 859-936-3537
  • Fax:
Mailing address:
  • Phone: 605-312-1000
  • Fax: 605-312-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number252059
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: