Provider Demographics
NPI:1417929043
Name:NALAZEK, BRIAN CHARLES (PT, OMPT, CWT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
Last Name:NALAZEK
Suffix:
Gender:M
Credentials:PT, OMPT, CWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18791 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2503
Mailing Address - Country:US
Mailing Address - Phone:586-790-2326
Mailing Address - Fax:586-790-2476
Practice Address - Street 1:18791 15 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2503
Practice Address - Country:US
Practice Address - Phone:586-790-2326
Practice Address - Fax:586-790-2476
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650E018080OtherBLUE CROSS PIN NUMBER
MI650E018080OtherBLUE CROSS PIN NUMBER