Provider Demographics
NPI:1114494713
Name:BROHM, LUCAS
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:
Last Name:BROHM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 SHADOWMEADE LN
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-6277
Mailing Address - Country:US
Mailing Address - Phone:502-538-2332
Mailing Address - Fax:502-538-2514
Practice Address - Street 1:190 SHADOWMEADE LN
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-6277
Practice Address - Country:US
Practice Address - Phone:502-538-2332
Practice Address - Fax:502-538-2514
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2251000000XMedicaid