Provider Demographics
NPI:1962187930
Name:RAK, BRIAN (PTA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RAK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 S WILLOW ST STE 128
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5723
Mailing Address - Country:US
Mailing Address - Phone:603-681-9294
Mailing Address - Fax:888-979-6551
Practice Address - Street 1:8480 CRAIG ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-4745
Practice Address - Country:US
Practice Address - Phone:317-578-7730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606237225200000X
NCDA7784225200000X
IN06005419A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant