Provider Demographics
NPI:1952851420
Name:BROCKEVELT, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BROCKEVELT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6226 S 194TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3723
Mailing Address - Country:US
Mailing Address - Phone:402-216-9478
Mailing Address - Fax:
Practice Address - Street 1:410 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:NE
Practice Address - Zip Code:68037-6006
Practice Address - Country:US
Practice Address - Phone:402-234-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-09
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1412225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant