Provider Demographics
NPI:1871746404
Name:CONCKLIN, BRENT JASON (LMHC)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:JASON
Last Name:CONCKLIN
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 ASHLEY OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6416
Mailing Address - Country:US
Mailing Address - Phone:813-308-9808
Mailing Address - Fax:
Practice Address - Street 1:2100 ASHLEY OAKS CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6416
Practice Address - Country:US
Practice Address - Phone:813-308-9808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6097101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health