Healthcare Provider Details

I. General information

NPI: 1144529561
Provider Name (Legal Business Name): BRET DEREK LICKTEIG D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17202 MIDLAND DR
SHAWNEE KS
66217-8901
US

IV. Provider business mailing address

17202 MIDLAND DR
SHAWNEE KS
66217-8901
US

V. Phone/Fax

Practice location:
  • Phone: 913-268-8300
  • Fax: 913-268-8390
Mailing address:
  • Phone: 913-268-8300
  • Fax: 913-268-8390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number01-05378
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: