Provider Demographics
NPI:1821494022
Name:BROCKWAY, DAVID (PSYD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 18TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-4816
Mailing Address - Country:US
Mailing Address - Phone:727-666-2429
Mailing Address - Fax:
Practice Address - Street 1:3730 18TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-4816
Practice Address - Country:US
Practice Address - Phone:727-666-2429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-15
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT102L00000X102L00000X
FL0471010316103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst