Healthcare Provider Details

I. General information

NPI: 1376786459
Provider Name (Legal Business Name): BRENT WHEELER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 04/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 N. LAMAR BLVD SUITE 354
AUSTIN TX
78705
US

IV. Provider business mailing address

2300 E. 8TH ST.
AUSTIN TX
78702
US

V. Phone/Fax

Practice location:
  • Phone: 512-786-0467
  • Fax: 254-519-3464
Mailing address:
  • Phone: 512-512-7860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15744
License Number StateTX

VIII. Authorized Official

Name: MR. BRENT WAYNE WHEELER
Title or Position: LPC, LSSP, LPA
Credential: MA
Phone: 512-786-0467