Provider Demographics
NPI:1033551387
Name:WING, BRENT J (CT,CDA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:J
Last Name:WING
Suffix:
Gender:M
Credentials:CT,CDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4449 STATE ROUTE 159
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8620
Mailing Address - Country:US
Mailing Address - Phone:740-772-7886
Mailing Address - Fax:
Practice Address - Street 1:102 DAWN LN
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9695
Practice Address - Country:US
Practice Address - Phone:740-947-7783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.130002101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor