Provider Demographics
NPI:1366107484
Name:KLEMENT, BROCK CONRAD (LPC)
Entity type:Individual
Prefix:MR
First Name:BROCK
Middle Name:CONRAD
Last Name:KLEMENT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:BROCK
Other - Middle Name:KLEMENT
Other - Last Name:HAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:527 13TH ST S APT 221
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-2157
Mailing Address - Country:US
Mailing Address - Phone:928-814-3279
Mailing Address - Fax:
Practice Address - Street 1:2501 HANLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8786
Practice Address - Country:US
Practice Address - Phone:534-544-5247
Practice Address - Fax:534-544-5248
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-18611101YM0800X
MN2751101YP2500X
WI10038-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health