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NPI Code Detail

MEDICARE: BRENT WHEELER

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
1101YP2500XProfessional Counselor
2103TS0200XSchool Psychologist
3106H00000XMarriage & Family Therapist
4101YM0800XMental Health Counselor15744TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
15301LCOTHERTXBLUE 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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