Provider Demographics
NPI:1588221337
Name:BOCKBRADER, BROOKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BOCKBRADER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6921 COUNTY ROAD 107
Mailing Address - Street 2:
Mailing Address - City:GIBSONBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43431-9536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 ST LAWRENCE DR STE 104
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8313
Practice Address - Country:US
Practice Address - Phone:419-455-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH016076225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist