Healthcare Provider Details

I. General information

NPI: 1982938437
Provider Name (Legal Business Name): AGATHA D BROCKIE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 05/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 WAYNE DR
RICHMOND KY
40475-2337
US

IV. Provider business mailing address

212 WAYNE DR
RICHMOND KY
40475-2337
US

V. Phone/Fax

Practice location:
  • Phone: 859-625-0564
  • Fax: 859-625-1109
Mailing address:
  • Phone: 859-625-0564
  • Fax: 859-625-1109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005510
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: