Provider Demographics
NPI:1669559134
Name:BROCKHAUS, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BROCKHAUS
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 1:12893 CAMBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-1603
Mailing Address - Country:US
Mailing Address - Phone:913-491-0982
Mailing Address - Fax:
Practice Address - Street 1:4500 W 107TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-4025
Practice Address - Country:US
Practice Address - Phone:913-341-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1101099OtherLICENSE#