Provider Demographics
NPI:1093105553
Name:BROCKHOUSE, KRISTINA MICHELLE (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:MICHELLE
Last Name:BROCKHOUSE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 WESLEY RD
Mailing Address - Street 2:P.O. BOX 166
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-3646
Mailing Address - Country:US
Mailing Address - Phone:260-925-3865
Mailing Address - Fax:
Practice Address - Street 1:1752 WESLEY RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-3646
Practice Address - Country:US
Practice Address - Phone:260-925-3865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005382A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical