Provider Demographics
NPI:1558041418
Name:VANVLACK, BRETT
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:VANVLACK
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 1:4835 SOUTHRIDGE CT APT 5
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-9377
Mailing Address - Country:US
Mailing Address - Phone:715-209-5201
Mailing Address - Fax:
Practice Address - Street 1:2217 DUNCAN RD
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724-1214
Practice Address - Country:US
Practice Address - Phone:715-568-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant