Provider Demographics
NPI:1659460749
Name:BROCK, PAULETTE ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PAULETTE
Middle Name:ANN
Last Name:BROCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 N DUNCAN RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-9560
Mailing Address - Country:US
Mailing Address - Phone:217-356-9712
Mailing Address - Fax:
Practice Address - Street 1:1900 E. MAIN
Practice Address - Street 2:DEPARTMENT OF VETERAN'S AFFAIRS
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-554-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker