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General NPI Number Information
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NPI Number | 1598444994
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Entity Type | Individual
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Provider Name | TARA SOFIA BROCK MA, LPC
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Gender | Female
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Dates
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Enumeration Date | 07/13/2023
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Last Update Date | 07/13/2023
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Provider Practice Location Address
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Address Line | 1135 CLIFTON AVE
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City | CLIFTON
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State | NJ
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Zip | 07013-3642
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Country | US
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Telephone | 973-988-4241
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Fax |
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Provider Business Mailing Address
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Address Line | 53 FAYSON LAKE RD
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City | KINNELON
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State | NJ
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Zip | 07405-3129
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Country | US
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Telephone | 516-480-9601
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 37PC00966300
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License Number State | NJ
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