Provider Demographics
NPI:1164720355
Name:BRACK, WAYNE ALAN (LMT, NCMTB)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:ALAN
Last Name:BRACK
Suffix:
Gender:M
Credentials:LMT, NCMTB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-5044
Mailing Address - Country:US
Mailing Address - Phone:772-807-1785
Mailing Address - Fax:772-905-8314
Practice Address - Street 1:236 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5044
Practice Address - Country:US
Practice Address - Phone:772-807-1785
Practice Address - Fax:772-905-8314
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 60306225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist