Provider Demographics
NPI:1962401166
Name:WIECK, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:WIECK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-3105
Mailing Address - Country:US
Mailing Address - Phone:940-264-8818
Mailing Address - Fax:940-264-8819
Practice Address - Street 1:1410 8TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-3105
Practice Address - Country:US
Practice Address - Phone:940-264-8818
Practice Address - Fax:940-264-8819
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ03612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122759OtherSUPERIOR
TX168446OtherCOMPSYCH
TX128381OtherMHN
TX5674356OtherFIRST HEALTH/CCN
TXMDJ0361OtherWORKERS COMPENSATION
TX126829100OtherFIRSTCARE
TX00T02FOtherBLUE CROSS BLUE SHIELD
TX115962602Medicaid
TX208776OtherVALUEOPTIONS
OK100158970AMedicaid
TX5982351OtherAETNA BEHAVIORAL HEALTH
TX115962602Medicaid
TX5674356OtherFIRST HEALTH/CCN
OK100158970AMedicaid