MEDICARE: MRS. KARLA SUE BROCKMAN MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist		IL

General Provider Information

NPI Number	:	1114933736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KARLA SUE BROCKMAN MSPT

Provider Business Mailing Address
First Line	:	11315 LAKE RD
Second Line	:
City	:	HIGHLAND
State	:	IL
Zip	:	62249-4023
Country	:	US
Telephone Number	:	618-644-5766
Fax Number	:	618-644-2102

Provider Business Practice Location Address
First Line	:	11315 LAKE RD
Second Line	:
City	:	HIGHLAND
State	:	IL
Zip	:	62249-4023
Country	:	US
Telephone Number	:	618-644-5766
Fax Number	:	618-644-2102

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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