Provider Demographics
NPI:1043795040
Name:WAGNER, BRENNA LYN (MSC, BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:BRENNA
Middle Name:LYN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSC, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:ERDA
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9799
Mailing Address - Country:US
Mailing Address - Phone:435-840-8166
Mailing Address - Fax:
Practice Address - Street 1:88 E 1000 N
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9693
Practice Address - Country:US
Practice Address - Phone:435-249-0934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11353635-2507106E00000X
106S00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician