Provider Demographics
NPI:1629478946
Name:BROCK, LISA G (MS, LAC, LAMFT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:G
Last Name:BROCK
Suffix:
Gender:F
Credentials:MS, LAC, LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FREE FERRY LNDG
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2248
Mailing Address - Country:US
Mailing Address - Phone:479-461-7789
Mailing Address - Fax:
Practice Address - Street 1:10301 MAYO DR
Practice Address - Street 2:
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923-1660
Practice Address - Country:US
Practice Address - Phone:479-494-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2015-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1408111101YM0800X
ARF1409010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist