Provider Demographics
NPI:1679098685
Name:BROCK, AMY ELIZABETH (PSY S; NCSP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:BROCK
Suffix:
Gender:F
Credentials:PSY S; NCSP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1217
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-1217
Mailing Address - Country:US
Mailing Address - Phone:276-328-8017
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1217
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-1217
Practice Address - Country:US
Practice Address - Phone:276-328-8017
Practice Address - Fax:276-328-8017
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000402103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool