Healthcare Provider Details

I. General information

NPI: 1518700285
Provider Name (Legal Business Name): BRONSON WALLACE BRYLAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 BURNET RD #103
AUSTIN TX
78728
US

IV. Provider business mailing address

129 MAPLEWOOD N
KYLE TX
78640-5276
US

V. Phone/Fax

Practice location:
  • Phone: 512-710-6516
  • Fax:
Mailing address:
  • Phone: 210-827-2577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number119497
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: