Provider Demographics
NPI:1780102764
Name:BROCHMAN, CARLY ANNE
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ANNE
Last Name:BROCHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3970 MULLAN RD APT 401
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5584
Mailing Address - Country:US
Mailing Address - Phone:651-353-9237
Mailing Address - Fax:
Practice Address - Street 1:3802 EASTSIDE HWY
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870-2224
Practice Address - Country:US
Practice Address - Phone:406-777-3523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60774080225100000X
MTPTP-PT-LIC-15223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist