Provider Demographics
NPI:1699262766
Name:BROCKINGTON, FREDERICK D (LAPC)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:D
Last Name:BROCKINGTON
Suffix:
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E PONCE DE LEON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3412
Mailing Address - Country:US
Mailing Address - Phone:678-753-5248
Mailing Address - Fax:404-585-3054
Practice Address - Street 1:235 E PONCE DE LEON AVE STE 103
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3412
Practice Address - Country:US
Practice Address - Phone:678-753-5248
Practice Address - Fax:404-585-3054
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-15
Last Update Date:2018-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006305101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional