Provider Demographics
NPI:1316001134
Name:BROCK, KELLY KOGA (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KOGA
Last Name:BROCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 INTERNATIONAL CIR # 2
Mailing Address - Street 2:PHYSICAL THERAPY DEPARTMENT
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1130
Mailing Address - Country:US
Mailing Address - Phone:408-972-6400
Mailing Address - Fax:408-972-3415
Practice Address - Street 1:270 INTERNATIONAL CIR # TWON
Practice Address - Street 2:PHYSICAL THERAPY
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1130
Practice Address - Country:US
Practice Address - Phone:408-972-6400
Practice Address - Fax:408-972-3415
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 11836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 11836OtherSTATE LICENSE