Provider Demographics
NPI:1043318371
Name:BROCKMAN, DALE B (PT)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:B
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 OBLIQUE ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1927
Mailing Address - Country:US
Mailing Address - Phone:859-371-1929
Mailing Address - Fax:859-371-2581
Practice Address - Street 1:13 OBLIQUE ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1927
Practice Address - Country:US
Practice Address - Phone:859-371-1929
Practice Address - Fax:859-371-2581
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000000010141225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87015004Medicaid
KY5015901Medicare UPIN