Provider Demographics
NPI:1154523835
Name:BROCKMAN-KNIGHT, ELISABETH LOUISE (MA, LPC)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:LOUISE
Last Name:BROCKMAN-KNIGHT
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:L
Other - Last Name:BROCKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1000 W NIFONG BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5615
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005025848101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506201904OtherHCY MEDICAID NUMBER
MO1649269622OtherBILLING NPI NUMBER
MO2005025848OtherSTATE LICENCE
MO1538204904OtherFACILITY NPI
MO431004805OtherFACILITY TAX ID