Provider Demographics
NPI:1255166567
Name:BROCK, DAESHANAE (LMFT)
Entity type:Individual
Prefix:
First Name:DAESHANAE
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 FOXWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-5203
Mailing Address - Country:US
Mailing Address - Phone:816-965-3036
Mailing Address - Fax:
Practice Address - Street 1:97 FOXWOOD TRL
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-5203
Practice Address - Country:US
Practice Address - Phone:816-965-3036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001982106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist