Provider Demographics
NPI:1972313484
Name:BROCK, SIMONE ELIZABETH (LAC)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:ELIZABETH
Last Name:BROCK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 AUSTIN LOOP
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:AR
Mailing Address - Zip Code:72045-9613
Mailing Address - Country:US
Mailing Address - Phone:972-342-1696
Mailing Address - Fax:
Practice Address - Street 1:271 AUSTIN LOOP
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:AR
Practice Address - Zip Code:72045-9613
Practice Address - Country:US
Practice Address - Phone:972-342-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2501003101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health