Provider Demographics
NPI:1992054738
Name:BROKAW, SUSAN M (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:BROKAW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:
Practice Address - Street 1:411 E IRELAND RD STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2681
Practice Address - Country:US
Practice Address - Phone:574-561-8950
Practice Address - Fax:574-231-8955
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501300653225100000X
IN05012405A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist