Provider Demographics
NPI:1679519953
Name:BROCK, DEBORAH LYNN (PHD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LYNN
Last Name:BROCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 LODI ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-1418
Mailing Address - Country:US
Mailing Address - Phone:608-592-2080
Mailing Address - Fax:608-592-7120
Practice Address - Street 1:336 LODI ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1418
Practice Address - Country:US
Practice Address - Phone:608-592-2080
Practice Address - Fax:608-592-7120
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2855-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional