Provider Demographics
NPI:1578867875
Name:BROCKWAY, HEATHER LYNN (LSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:SOCEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-694-0004
Practice Address - Street 1:4285 N RANCHO DR
Practice Address - Street 2:STE 130
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3446
Practice Address - Country:US
Practice Address - Phone:702-385-5331
Practice Address - Fax:702-385-5678
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
NV5839-S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner