1750485850 NPI number — DR. JAMES VAUGHN BROCK JR. MDIV., PSYD., L.S.W.

Table of content: (NPI 1568488682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750485850 NPI number — DR. JAMES VAUGHN BROCK JR. MDIV., PSYD., L.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
JAMES
Provider Middle Name:
VAUGHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MDIV., PSYD., L.S.W.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750485850
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DOUGHERTY COUNSELING CENTER
Provider Second Line Business Mailing Address:
1919 STATE ST., STE. #2
Provider Business Mailing Address City Name:
NEW ALBANY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-944-2532
Provider Business Mailing Address Fax Number:
812-944-2549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DOUGHERTY COUNSELING CENTER
Provider Second Line Business Practice Location Address:
1919 STATE ST., STE. #2
Provider Business Practice Location Address City Name:
NEW ALBANY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-944-2532
Provider Business Practice Location Address Fax Number:
812-944-2549
Provider Enumeration Date:
09/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  33001554A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 2009-100 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11438111 . This is a "CAQH PROVIDER #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".