Provider Demographics
NPI:1134423445
Name:FALCK, BRIAN KEITH (LCSW)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:FALCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8809 BUS HWY 13
Mailing Address - Street 2:
Mailing Address - City:WESTBORO
Mailing Address - State:WI
Mailing Address - Zip Code:54490-9444
Mailing Address - Country:US
Mailing Address - Phone:920-475-7668
Mailing Address - Fax:
Practice Address - Street 1:N8809 BUS HWY 13
Practice Address - Street 2:
Practice Address - City:WESTBORO
Practice Address - State:WI
Practice Address - Zip Code:54490-9444
Practice Address - Country:US
Practice Address - Phone:920-475-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1996-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health