Healthcare Provider Details

I. General information

NPI: 1518156314
Provider Name (Legal Business Name): ANNIE R. BROCK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N LAFAYETTE DR
SUMTER SC
29150-4347
US

IV. Provider business mailing address

1278 N. LAFAYETTE DRIVE
SUMTER SC
29150-2964
US

V. Phone/Fax

Practice location:
  • Phone: 803-775-6293
  • Fax: 803-775-7593
Mailing address:
  • Phone: 803-774-4500
  • Fax: 803-774-4626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8922
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8922
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: