Provider Demographics
NPI:1811775943
Name:BROCK, TRAEQUANDA (LGSW, LMSW)
Entity type:Individual
Prefix:MS
First Name:TRAEQUANDA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:LGSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MERCANTILE LN STE 433
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4301
Mailing Address - Country:US
Mailing Address - Phone:518-364-4481
Mailing Address - Fax:240-823-1424
Practice Address - Street 1:440 PENN ST NE APT 520
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-8373
Practice Address - Country:US
Practice Address - Phone:518-364-4481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50083546104100000X
NJ44SL07023200104100000X
374J00000X
MD26217104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No374J00000XNursing Service Related ProvidersDoula