Provider Demographics
NPI:1205069549
Name:BROCK, EDWARD LEE (LMHC, MDIV, DMIN)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:LEE
Last Name:BROCK
Suffix:
Gender:M
Credentials:LMHC, MDIV, DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23030 97TH AVE W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-5009
Mailing Address - Country:US
Mailing Address - Phone:425-773-4144
Mailing Address - Fax:
Practice Address - Street 1:115 N 85TH ST
Practice Address - Street 2:#202
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-3653
Practice Address - Country:US
Practice Address - Phone:425-773-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60017490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health