Provider Demographics
NPI:1447912902
Name:BROCKETT, JULIA
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:BROCKETT
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 1:135 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-1209
Mailing Address - Country:US
Mailing Address - Phone:203-558-8028
Mailing Address - Fax:
Practice Address - Street 1:15 BERKSHIRE RD
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:CT
Practice Address - Zip Code:06482-1361
Practice Address - Country:US
Practice Address - Phone:203-270-4335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2368101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health