Healthcare Provider Details

I. General information

NPI: 1164071734
Provider Name (Legal Business Name): MERIDITH JAMES BROCK LPCC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MERIDITH JAMES BROCK LPCC, LPC

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date: 02/13/2023
Reactivation Date: 06/11/2026

III. Provider practice location address

4501 SHEPARD RD NE APT C106
ALBUQUERQUE NM
87110-1803
US

IV. Provider business mailing address

4501 SHEPARD RD NE APT C106
ALBUQUERQUE NM
87110-1803
US

V. Phone/Fax

Practice location:
  • Phone: 669-290-2711
  • Fax:
Mailing address:
  • Phone: 669-290-2711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2026-0475
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: