Provider Demographics
NPI:1184072753
Name:BROCKMAN, ALEXANDRA NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:NICOLE
Other - Last Name:DEVILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2025 NE BAKER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-2656
Mailing Address - Country:US
Mailing Address - Phone:503-435-1900
Mailing Address - Fax:503-435-1930
Practice Address - Street 1:2025 NE BAKER ST
Practice Address - Street 2:SUITE A
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2656
Practice Address - Country:US
Practice Address - Phone:503-435-1900
Practice Address - Fax:503-435-1930
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT61648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist