Provider Demographics
NPI:1508006206
Name:BROCK, CYNTHIA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 CROOKED HILL RD
Mailing Address - Street 2:BUILDING 5 OUTPATIENT DEPARTMENT
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1019
Mailing Address - Country:US
Mailing Address - Phone:631-306-5740
Mailing Address - Fax:631-306-5885
Practice Address - Street 1:998 CROOKED HILL RD
Practice Address - Street 2:BUILDING 5 OUTPATIENT DEPARTMENT
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1019
Practice Address - Country:US
Practice Address - Phone:631-306-5740
Practice Address - Fax:631-306-5885
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP68923104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01035285Medicaid