Provider Demographics
NPI:1750485850
Name:BROCK, JAMES VAUGHN JR (MDIV, PSYD, LSW)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:VAUGHN
Last Name:BROCK
Suffix:JR
Gender:M
Credentials:MDIV, PSYD, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DOUGHERTY COUNSELING CENTER
Mailing Address - Street 2:1919 STATE ST., STE. #2
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150
Mailing Address - Country:US
Mailing Address - Phone:812-944-2532
Mailing Address - Fax:812-944-2549
Practice Address - Street 1:DOUGHERTY COUNSELING CENTER
Practice Address - Street 2:1919 STATE ST., STE. #2
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150
Practice Address - Country:US
Practice Address - Phone:812-944-2532
Practice Address - Fax:812-944-2549
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33001554A104100000X
KY2009-100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11438111OtherCAQH PROVIDER #