Provider Demographics
NPI:1962048579
Name:BROCKELMAN, MIRA
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:BROCKELMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-7002
Mailing Address - Country:US
Mailing Address - Phone:971-275-2854
Mailing Address - Fax:
Practice Address - Street 1:204 S 1ST ST
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540-7002
Practice Address - Country:US
Practice Address - Phone:971-275-2854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist