1962401166 NPI number — BRYAN WIECK

Table of content: BRYAN WIECK (NPI 1962401166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962401166 NPI number — BRYAN WIECK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIECK
Provider First Name:
BRYAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962401166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1819 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA FALLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76301-4212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-322-9456
Provider Business Mailing Address Fax Number:
940-322-6759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1819 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76301-4212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-322-9456
Provider Business Practice Location Address Fax Number:
940-322-6759
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  J0361 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 122759 . This is a "SUPERIOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 128381 . This is a "MHN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 208776 . This is a "VALUEOPTIONS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 115962602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 126829100 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 168446 . This is a "COMPSYCH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00T02F . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 100158970A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MDJ0361 . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5982351 . This is a "AETNA BEHAVIORAL HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5674356 . This is a "FIRST HEALTH/CCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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