Provider Demographics
NPI:1114933736
Name:BROCKMAN, KARLA SUE (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:KARLA
Middle Name:SUE
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11315 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-4023
Mailing Address - Country:US
Mailing Address - Phone:618-644-5766
Mailing Address - Fax:618-644-2102
Practice Address - Street 1:11315 LAKE RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-4023
Practice Address - Country:US
Practice Address - Phone:618-644-5766
Practice Address - Fax:618-644-2102
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics