Provider Demographics
NPI:1952775355
Name:BROCKEL, CANDICE VICTORIA (DPT)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:VICTORIA
Last Name:BROCKEL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:713 W WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1307
Practice Address - Country:US
Practice Address - Phone:864-479-6084
Practice Address - Fax:864-479-6091
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01646600225100000X
SC11895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist