Provider Demographics
NPI:1235807066
Name:BROCKELMAN, DANIELLE N
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:N
Last Name:BROCKELMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:N
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3818 TIMBERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6927
Mailing Address - Country:US
Mailing Address - Phone:903-520-8890
Mailing Address - Fax:
Practice Address - Street 1:185 S KIMBALL AVE STE 120
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-1525
Practice Address - Country:US
Practice Address - Phone:214-618-0588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81931101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional