Provider Demographics
NPI:1366988859
Name:WALKOWIAK, BREANNE (PT, DPT)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:WALKOWIAK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29255 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1018
Mailing Address - Country:US
Mailing Address - Phone:248-353-1234
Mailing Address - Fax:242-353-1211
Practice Address - Street 1:3435 LIVERNOIS RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5063
Practice Address - Country:US
Practice Address - Phone:242-353-1234
Practice Address - Fax:248-743-1237
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010180025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist