Provider Demographics
NPI:1932513249
Name:BROCK, YVONNE (CAC-AD)
Entity type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 W ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-3503
Mailing Address - Country:US
Mailing Address - Phone:301-821-3805
Mailing Address - Fax:
Practice Address - Street 1:1308 W ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-3503
Practice Address - Country:US
Practice Address - Phone:301-821-3805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDACO340101YA0400X, 171W00000X, 174H00000X, 225C00000X
MDAC0340171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No174H00000XOther Service ProvidersHealth Educator
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor