Provider Demographics
NPI:1902116635
Name:SPAKO, BRIAN T (BS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:SPAKO
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1529
Mailing Address - Country:US
Mailing Address - Phone:716-945-5211
Mailing Address - Fax:716-945-5267
Practice Address - Street 1:97 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-1529
Practice Address - Country:US
Practice Address - Phone:716-945-5211
Practice Address - Fax:716-945-5267
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00625098Medicaid