Provider Demographics
NPI:1306379565
Name:WALCK, BRIANA
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:WALCK
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 1:6490 TAYLOR RD LOT 17
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-6565
Mailing Address - Country:US
Mailing Address - Phone:877-246-2396
Mailing Address - Fax:
Practice Address - Street 1:6490 TAYLOR RD LOT 17
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-6565
Practice Address - Country:US
Practice Address - Phone:239-687-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist