Healthcare Provider Details

I. General information

NPI: 1386002459
Provider Name (Legal Business Name): KRISTIN BROCKFELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 MEXICO RD STE 104
SAINT PETERS MO
63376-1666
US

IV. Provider business mailing address

1428 W MEYER RD
WENTZVILLE MO
63385-3499
US

V. Phone/Fax

Practice location:
  • Phone: 636-887-3660
  • Fax:
Mailing address:
  • Phone: 636-887-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2016003549
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: