Provider Demographics
NPI:1467199869
Name:VAN BROCKLIN, DENISE MARIE (SSP, NCSP)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:VAN BROCKLIN
Suffix:
Gender:F
Credentials:SSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2275
Mailing Address - Country:US
Mailing Address - Phone:330-723-7977
Mailing Address - Fax:330-725-5177
Practice Address - Street 1:230 S COURT ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2275
Practice Address - Country:US
Practice Address - Phone:330-723-7977
Practice Address - Fax:330-725-5177
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4061936103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool