MEDICARE: BRITTNEY WAGNER BCBA

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	103K00000X	Behavior Analyst	BEH-000864	AZ

General Provider Information

NPI Number	:	1437520533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRITTNEY WAGNER BCBA

Provider Business Mailing Address
First Line	:	27777 INKSTER RD STE 100
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-5312
Country	:	US
Telephone Number	:	855-772-8847
Fax Number	:

Provider Business Practice Location Address
First Line	:	13615 N 35TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-1243
Country	:	US
Telephone Number	:	855-772-8847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2015
Last Update Date	:	02/06/2025

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