Healthcare Provider Details

I. General information

NPI: 1336715747
Provider Name (Legal Business Name): BLAKE C OVERMILLER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12938 E 21ST ST N STE 120
WICHITA KS
67230-7410
US

IV. Provider business mailing address

13420 BRIAR DR STE C
LEAWOOD KS
66209-3434
US

V. Phone/Fax

Practice location:
  • Phone: 316-285-0757
  • Fax:
Mailing address:
  • Phone: 913-484-7632
  • Fax: 913-808-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: