Healthcare Provider Details

I. General information

NPI: 1689179285
Provider Name (Legal Business Name): BRIAN JAMES WOHLWEND BCBA, M.ED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12205 WILDBROOK DR
RIVERVIEW FL
33569-4111
US

IV. Provider business mailing address

12205 WILDBROOK DR
RIVERVIEW FL
33569-4111
US

V. Phone/Fax

Practice location:
  • Phone: 813-748-2477
  • Fax:
Mailing address:
  • Phone: 813-748-2477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-10015
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: