=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851864821
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWNNEICE BETH BROCK MSW, LICSW, PIP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2019
-----------------------------------------------------
Last Update Date | 01/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SPARKS CENTER 1720 7TH AVENUE SOUTH- 9TH FLOOR
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35294-0017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-934-5201
-----------------------------------------------------
Fax | 205-975-4879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | SPARKS CENTER 1720 7TH AVENUE SOUTH- 9TH FLOOR
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35294-0017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-934-5201
-----------------------------------------------------
Fax | 205-975-4879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0581C
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------