Healthcare Provider Details

I. General information

NPI: 1275502148
Provider Name (Legal Business Name): BROCK A BOEKHOUT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-9873
  • Fax: 620-231-2808
Mailing address:
  • Phone: 620-231-9873
  • Fax: 620-231-2808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1346
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: