Provider Demographics
NPI:1508950858
Name:BROCK, MELISSA JILL (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JILL
Last Name:BROCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JILL
Other - Last Name:PICKENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:926 W OAKLAND AVE
Mailing Address - Street 2:SUITE 226
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-1445
Mailing Address - Country:US
Mailing Address - Phone:423-929-0300
Mailing Address - Fax:423-928-4563
Practice Address - Street 1:926 W OAKLAND AVE
Practice Address - Street 2:SUITE 226
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-1445
Practice Address - Country:US
Practice Address - Phone:423-929-0300
Practice Address - Fax:423-926-8840
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLCSW39391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical