Active NPI
Wanda Clarice Brock, LPC
- Professional Counselor
- Henderson, NC
National Provider Identifier
1912112699
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- 4481
- Practice address
- 510 Dabney Dr
Henderson, NC 27536-3946 - Phone
- (252) 431-0072
- Fax
- (252) 431-0490
- NPI assigned
- May 14, 2007
- Last updated
- Jul 8, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | 4481 | NC | Primary |
Addresses
Primary practice location
510 Dabney Dr
Henderson, NC 27536-3946
Mailing address
3129 Marengo Rd
La Crosse, VA 23950-2420
Phone (434) 636-2792
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 6102736 | Medicaid | NC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4481 | NC | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1179100800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1912112699",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3129 MARENGO RD",
"city": "LA CROSSE",
"state": "VA",
"postal_code": "239502420",
"telephone_number": "434-636-2792"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "510 DABNEY DR",
"city": "HENDERSON",
"state": "NC",
"postal_code": "275363946",
"telephone_number": "252-431-0072",
"fax_number": "252-431-0490"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BROCK",
"first_name": "WANDA",
"middle_name": "CLARICE",
"name_prefix": "Ms.",
"credential": "LPC",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-05-14",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "NC",
"license": "4481",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "6102736",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Henderson, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.