Healthcare Provider Details

I. General information

NPI: 1194702498
Provider Name (Legal Business Name): TIFFANY C BROECKELMAN MSPT, CERT MDT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7931 BOND ST
LENEXA KS
66214-1557
US

IV. Provider business mailing address

6816 W 77TH TER
OVERLAND PARK KS
66204-3161
US

V. Phone/Fax

Practice location:
  • Phone: 913-754-0888
  • Fax: 913-754-0891
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number11-02793
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number11-02793
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: