Basic Information
| Provider Information | |||||||||
| NPI: | 1518156314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1278 N. LAFAYETTE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291502964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
| FaxNumber: | 8037744626 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 N LAFAYETTE DR | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291504347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037756293 | ||||||||
| FaxNumber: | 8037757593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 8922 | SC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 8922 | SC | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.