Provider Demographics
NPI:1518142199
Name:BROCKMON, CAROL (MSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:BROCKMON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7919 PARK AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-2645
Mailing Address - Country:US
Mailing Address - Phone:215-782-1484
Mailing Address - Fax:215-780-1848
Practice Address - Street 1:7919 PARK AVE APT 1
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2645
Practice Address - Country:US
Practice Address - Phone:215-782-1484
Practice Address - Fax:215-780-1848
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW000904L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical