Healthcare Provider Details

I. General information

NPI: 1508799768
Provider Name (Legal Business Name): BRIAN CRAIG WASILEWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W VILLARD ST
BOZEMAN MT
59715-3354
US

IV. Provider business mailing address

905 W VILLARD ST
BOZEMAN MT
59715-3354
US

V. Phone/Fax

Practice location:
  • Phone: 973-820-1301
  • Fax:
Mailing address:
  • Phone: 973-820-1301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-LMT-LIC-31767
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: