Provider Demographics
NPI:1295275097
Name:BROCKMAN, ANDREA R (NCC, LMHC)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:R
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1239
Mailing Address - Country:US
Mailing Address - Phone:727-327-7656
Mailing Address - Fax:727-328-8978
Practice Address - Street 1:4024 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1239
Practice Address - Country:US
Practice Address - Phone:727-327-7656
Practice Address - Fax:727-328-8978
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17599101YM0800X
IL180010802101YM0800X
IL178011935101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health