Provider Demographics
NPI:1942848650
Name:WILANTOWICZ, BRIAN (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WILANTOWICZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CARLYLE PL
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-1304
Mailing Address - Country:US
Mailing Address - Phone:914-843-7902
Mailing Address - Fax:914-723-1563
Practice Address - Street 1:55 PALMER AVE
Practice Address - Street 2:
Practice Address - City:BRONXVILLE
Practice Address - State:NY
Practice Address - Zip Code:10708-3403
Practice Address - Country:US
Practice Address - Phone:914-723-1642
Practice Address - Fax:914-723-1563
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018569-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist