Healthcare Provider Details

I. General information

NPI: 1669462479
Provider Name (Legal Business Name): MELISSA BLOCKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DR BROOKE ARMY MEDICAL CENTER, MCHE-QD/CREDENTIALS
FORT SAM HOUSTON TX
78234-4501
US

IV. Provider business mailing address

414 WOOD SHADOW ST
SAN ANTONIO TX
78216-1636
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-2350
  • Fax:
Mailing address:
  • Phone: 210-495-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19114
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: