Provider Demographics
NPI:1598444994
Name:BROCK, TARA SOFIA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:SOFIA
Last Name:BROCK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 FAYSON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-3129
Mailing Address - Country:US
Mailing Address - Phone:516-480-9601
Mailing Address - Fax:
Practice Address - Street 1:1135 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3642
Practice Address - Country:US
Practice Address - Phone:973-988-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00966300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional