Provider Demographics
NPI:1518700285
Name:BRYLAK, BRONSON WALLACE
Entity type:Individual
Prefix:
First Name:BRONSON
Middle Name:WALLACE
Last Name:BRYLAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 MAPLEWOOD N
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5276
Mailing Address - Country:US
Mailing Address - Phone:210-827-2577
Mailing Address - Fax:
Practice Address - Street 1:3915 BURNET RD
Practice Address - Street 2:#103
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728
Practice Address - Country:US
Practice Address - Phone:512-710-6516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119497235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist