Provider Demographics
NPI:1235970989
Name:BROCKMAN, PENNY
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 MCLAWS CIR STE 1A
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5860
Mailing Address - Country:US
Mailing Address - Phone:757-251-0225
Mailing Address - Fax:
Practice Address - Street 1:4451 LONGHILL RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-1534
Practice Address - Country:US
Practice Address - Phone:757-755-4149
Practice Address - Fax:757-282-2989
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013743101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional