Provider Demographics
NPI:1811870124
Name:BROCKMAN, LAURA (PSYD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 NJ-66
Mailing Address - Street 2:SUITE 331
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07753
Mailing Address - Country:US
Mailing Address - Phone:732-988-3441
Mailing Address - Fax:
Practice Address - Street 1:4000 NJ-66
Practice Address - Street 2:SUITE 331
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07753
Practice Address - Country:US
Practice Address - Phone:732-988-3441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ253-003390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty