Provider Demographics
NPI:1164072401
Name:BROCK, KAN'DACE LEN (LMSW)
Entity Type:Individual
Prefix:
First Name:KAN'DACE
Middle Name:LEN
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7126 WATERTROUT BAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-1778
Mailing Address - Country:US
Mailing Address - Phone:817-291-6942
Mailing Address - Fax:
Practice Address - Street 1:7126 WATERTROUT BAY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1778
Practice Address - Country:US
Practice Address - Phone:817-291-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54904104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty