Provider Demographics
NPI:1912112699
Name:BROCK, WANDA CLARICE (LPC)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:CLARICE
Last Name:BROCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 MARENGO RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:VA
Mailing Address - Zip Code:23950-2420
Mailing Address - Country:US
Mailing Address - Phone:434-636-2792
Mailing Address - Fax:
Practice Address - Street 1:510 DABNEY DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-3946
Practice Address - Country:US
Practice Address - Phone:252-431-0072
Practice Address - Fax:252-431-0490
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4481101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102736Medicaid