Provider Demographics
NPI:1316653199
Name:BROCK, PORTIA (LPC)
Entity type:Individual
Prefix:MRS
First Name:PORTIA
Middle Name:
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 1:3152 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-3425
Mailing Address - Country:US
Mailing Address - Phone:773-512-6773
Mailing Address - Fax:
Practice Address - Street 1:566 W LAKE ST STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1413
Practice Address - Country:US
Practice Address - Phone:312-371-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178018863101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health