Provider Demographics
NPI:1871766824
Name:BROCK, MABEL KATHERINE (LMFT, LPC, RN)
Entity type:Individual
Prefix:
First Name:MABEL
Middle Name:KATHERINE
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMFT, LPC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 BENTON RD
Mailing Address - Street 2:SUITE D-202
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-7933
Mailing Address - Country:US
Mailing Address - Phone:318-347-0486
Mailing Address - Fax:318-965-0904
Practice Address - Street 1:2285 BENTON RD
Practice Address - Street 2:SUITE D-202
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7933
Practice Address - Country:US
Practice Address - Phone:318-347-0486
Practice Address - Fax:318-965-0904
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2677101YP2500X
LA392106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional