Provider Demographics
NPI:1235907916
Name:WALLICK, BRANDON RICHARD (DHSC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:RICHARD
Last Name:WALLICK
Suffix:
Gender:M
Credentials:DHSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5265 ROCKROSE LN BLDG E38
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-8250
Mailing Address - Country:US
Mailing Address - Phone:267-797-0240
Mailing Address - Fax:
Practice Address - Street 1:5265 ROCKROSE LN BLDG E38
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-8250
Practice Address - Country:US
Practice Address - Phone:267-797-0240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist