Provider Demographics
NPI:1609152735
Name:ATHEY, BROCK WAYNE (MPT)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:WAYNE
Last Name:ATHEY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 W EVERGREEN AVE
Mailing Address - Street 2:BIOMAX STE 102
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401
Mailing Address - Country:US
Mailing Address - Phone:217-343-3400
Mailing Address - Fax:217-342-9714
Practice Address - Street 1:1303 W EVERGREEN AVE
Practice Address - Street 2:BIOMAX STE 102
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401
Practice Address - Country:US
Practice Address - Phone:217-343-3400
Practice Address - Fax:217-342-9714
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018141225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist