Provider Demographics
NPI:1356625867
Name:BROCK, CYNTHIA (LISW)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4508 HARPERS FERRY CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3851
Mailing Address - Country:US
Mailing Address - Phone:505-385-5454
Mailing Address - Fax:
Practice Address - Street 1:4508 HARPERS FERRY CT NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-3851
Practice Address - Country:US
Practice Address - Phone:505-385-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-058911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical