Provider Demographics
NPI:1033523915
Name:BRILL, WADE (PSYD)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:BRILL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 OLIVESBURG RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-1228
Mailing Address - Country:US
Mailing Address - Phone:419-526-2100
Mailing Address - Fax:419-521-2822
Practice Address - Street 1:1001 OLIVESBURG RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-1228
Practice Address - Country:US
Practice Address - Phone:419-526-2100
Practice Address - Fax:419-521-2822
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4969103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral