Provider Demographics
NPI:1790050045
Name:BROCKMAN, MARY PATRICIA (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 N CARROLLTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-4707
Mailing Address - Country:US
Mailing Address - Phone:504-269-6006
Mailing Address - Fax:504-894-1008
Practice Address - Street 1:644 N CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-4707
Practice Address - Country:US
Practice Address - Phone:504-269-6006
Practice Address - Fax:504-894-1008
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA574103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent