Provider Demographics
NPI:1790854701
Name:MELROY, BRENT (PT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:MELROY
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 1:12112 W KELLOGG ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-1100
Mailing Address - Country:US
Mailing Address - Phone:316-440-1100
Mailing Address - Fax:316-440-1089
Practice Address - Street 1:4940 W. 137TH ST.
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66224-6622
Practice Address - Country:US
Practice Address - Phone:913-232-9846
Practice Address - Fax:913-232-9817
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-036532251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200429520BMedicaid
KS11-03653OtherPT LICENSE
KS200429520BMedicaid