Healthcare Provider Details

I. General information

NPI: 1679519953
Provider Name (Legal Business Name): DEBORAH LYNN BROCK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 LODI ST
LODI WI
53555-1418
US

IV. Provider business mailing address

336 LODI ST
LODI WI
53555-1418
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-2080
  • Fax: 608-592-7120
Mailing address:
  • Phone: 608-592-2080
  • Fax: 608-592-7120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2855-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: