MEDICARE: MRS. PORTIA BROCK LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	178018863	IL

General Provider Information

NPI Number	:	1316653199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PORTIA BROCK LPC

Provider Business Mailing Address
First Line	:	3152 W 84TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-3425
Country	:	US
Telephone Number	:	773-512-6773
Fax Number	:

Provider Business Practice Location Address
First Line	:	566 W LAKE ST STE 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-1413
Country	:	US
Telephone Number	:	312-371-5680
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2023
Last Update Date	:	01/25/2023

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Directions to “ MRS. PORTIA BROCK LPC” Practice Location

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