Provider Demographics
NPI:1255194825
Name:BROCKEL, DYLAN
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:BROCKEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15992 CALA ROJO DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80926-9314
Mailing Address - Country:US
Mailing Address - Phone:719-371-4372
Mailing Address - Fax:
Practice Address - Street 1:15992 CALA ROJO DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80926-9314
Practice Address - Country:US
Practice Address - Phone:719-371-4372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant