Provider Demographics
NPI:1073386579
Name:SIMRAK, BRIAN THOMAS
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:SIMRAK
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 1:7419 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4431
Mailing Address - Country:US
Mailing Address - Phone:714-604-5238
Mailing Address - Fax:
Practice Address - Street 1:7419 33RD AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4431
Practice Address - Country:US
Practice Address - Phone:714-604-5238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4127-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant