Provider Demographics
NPI:1295742963
Name:BROCK, SANDRA ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ANN
Last Name:BROCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 SHILOH DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4935
Mailing Address - Country:US
Mailing Address - Phone:281-438-0585
Mailing Address - Fax:281-438-0595
Practice Address - Street 1:2927 SHILOH DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-4935
Practice Address - Country:US
Practice Address - Phone:281-438-0585
Practice Address - Fax:281-438-0595
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX271301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037740001Medicaid
TX80907WMedicare PIN