Provider Demographics
NPI:1053985812
Name:FIALEK, BREANNA LACEY
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:LACEY
Last Name:FIALEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3370 S HILTON PARK RD
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9764
Mailing Address - Country:US
Mailing Address - Phone:231-670-1836
Mailing Address - Fax:
Practice Address - Street 1:570 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1323
Practice Address - Country:US
Practice Address - Phone:231-670-1836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist