Provider Demographics
NPI:1689874810
Name:VAN BROCKLIN, GARRET LEE (PT)
Entity Type:Individual
Prefix:
First Name:GARRET
Middle Name:LEE
Last Name:VAN BROCKLIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-2039
Mailing Address - Country:US
Mailing Address - Phone:402-223-7341
Mailing Address - Fax:402-223-6511
Practice Address - Street 1:1110 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-2039
Practice Address - Country:US
Practice Address - Phone:402-223-7341
Practice Address - Fax:402-223-6511
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist