Provider Demographics
NPI:1356493936
Name:BROCKETT, SHERYL A (LCPC C)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:A
Last Name:BROCKETT
Suffix:
Gender:F
Credentials:LCPC C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PROUTY DRIVE
Mailing Address - Street 2:
Mailing Address - City:VEAZIE
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-942-3907
Mailing Address - Fax:
Practice Address - Street 1:33 PENN PLZ STE C
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3619
Practice Address - Country:US
Practice Address - Phone:207-949-0717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL2972101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional