MEDICARE: BRENT WHEELER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	103TS0200X	School Psychologist
3	106H00000X	Marriage & Family Therapist
4	101YM0800X	Mental Health Counselor	15744	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5301LC	OTHER	TX	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1376786459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENT WHEELER

Provider Business Mailing Address
First Line	:	2300 E. 8TH ST.
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78702
Country	:	US
Telephone Number	:	512-512-7860
Fax Number	:

Provider Business Practice Location Address
First Line	:	1907 N. LAMAR BLVD
Second Line	:	SUITE 354
City	:	AUSTIN
State	:	TX
Zip	:	78705
Country	:	US
Telephone Number	:	512-786-0467
Fax Number	:	254-519-3464

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

Provider Enumeration Date	:	04/20/2009
Last Update Date	:	04/20/2009

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Directions to “BRENT WHEELER ” Practice Location

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