Provider Demographics
NPI:1538677117
Name:IWANICKI, BRIAN ROMAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROMAN
Last Name:IWANICKI
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 1:4870 N TALMAN AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-8156
Mailing Address - Country:US
Mailing Address - Phone:847-212-9373
Mailing Address - Fax:
Practice Address - Street 1:1265 HARTREY AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1056
Practice Address - Country:US
Practice Address - Phone:847-212-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst