Provider Demographics
NPI:1720308778
Name:VAN DEN BROECK, KARIN MARIA (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:KARIN
Middle Name:MARIA
Last Name:VAN DEN BROECK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2496
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46904-2496
Mailing Address - Country:US
Mailing Address - Phone:765-454-5340
Mailing Address - Fax:765-454-5347
Practice Address - Street 1:1220 LAGUNA ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-2330
Practice Address - Country:US
Practice Address - Phone:765-454-5340
Practice Address - Fax:765-454-5347
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005306A225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist