Provider Demographics
NPI:1205401106
Name:WOODARD, BROCK
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:WOODARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7105 CROSSROADS BLVD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2806
Mailing Address - Country:US
Mailing Address - Phone:615-690-4513
Mailing Address - Fax:
Practice Address - Street 1:7105 CROSSROADS BLVD STE 107
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-2806
Practice Address - Country:US
Practice Address - Phone:615-690-4513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2482101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional