Healthcare Provider Details

I. General information

NPI: 1245301613
Provider Name (Legal Business Name): BRIAN E GAJAFSKY PT CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CHEYENNE CT
GRAFTON WI
53024-0368
US

IV. Provider business mailing address

333 CEDAR CREST LN
SLINGER WI
53086-9079
US

V. Phone/Fax

Practice location:
  • Phone: 262-375-1075
  • Fax: 262-375-4975
Mailing address:
  • Phone: 414-774-8545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5497024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: