Provider Demographics
NPI:1508858952
Name:BROCKMAN, HOWARD LAURENCE (LCSW)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:LAURENCE
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4312
Mailing Address - Country:US
Mailing Address - Phone:503-370-4546
Mailing Address - Fax:503-370-4546
Practice Address - Street 1:1620 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4312
Practice Address - Country:US
Practice Address - Phone:503-370-4546
Practice Address - Fax:503-370-4546
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical