Provider Demographics
NPI:1093439341
Name:BROCKSMITH, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:BROCKSMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 METRO BLVD
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-2412
Mailing Address - Country:US
Mailing Address - Phone:314-395-9375
Mailing Address - Fax:314-942-1382
Practice Address - Street 1:2644 METRO BLVD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-2412
Practice Address - Country:US
Practice Address - Phone:314-395-9375
Practice Address - Fax:314-942-1382
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022014016103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst