Provider Demographics
NPI:1720367527
Name:BROECKER, KATHRYN ANN
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:ANN
Last Name:BROECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KATHRYN
Other - Middle Name:ANN
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MS
Mailing Address - Street 1:2508 DUNHAM RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-2424
Mailing Address - Country:US
Mailing Address - Phone:804-360-8755
Mailing Address - Fax:
Practice Address - Street 1:1257 MARYWOOD LN
Practice Address - Street 2:REHABILITATION DEPT.
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-6059
Practice Address - Country:US
Practice Address - Phone:804-741-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23050008012251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305000801OtherPT LICENSE NUMBER