Healthcare Provider Details

I. General information

NPI: 1679401491
Provider Name (Legal Business Name): KYLIE BROCK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 COLLEGE AVE STE G200
MANHATTAN KS
66502-2934
US

IV. Provider business mailing address

24014 W RENWICK RD STE 206
PLAINFIELD IL
60544-8711
US

V. Phone/Fax

Practice location:
  • Phone: 800-974-4378
  • Fax: 630-515-1536
Mailing address:
  • Phone: 800-974-4378
  • Fax: 630-515-1536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-04318
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: