Provider Demographics
NPI:1629478946
Name:BROCK, LISA G (MS, LPC, LMFT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:G
Last Name:BROCK
Suffix:
Gender:F
Credentials:MS, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 GATEHOUSE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-6022
Mailing Address - Country:US
Mailing Address - Phone:479-461-7789
Mailing Address - Fax:
Practice Address - Street 1:2200 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3088
Practice Address - Country:US
Practice Address - Phone:479-242-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARM1807017106H00000X
ARP1808107101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist