Provider Demographics
NPI:1114088952
Name:BROCKS, KIRK DOUGLAS (LMFT)
Entity Type:Individual
Prefix:MR
First Name:KIRK
Middle Name:DOUGLAS
Last Name:BROCKS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 REDWOOD ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3608
Mailing Address - Country:US
Mailing Address - Phone:707-642-4015
Mailing Address - Fax:707-642-8319
Practice Address - Street 1:2103 REDWOOD ST
Practice Address - Street 2:SUITE 204
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-3608
Practice Address - Country:US
Practice Address - Phone:707-642-4015
Practice Address - Fax:707-642-8319
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32561106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist