Provider Demographics
NPI:1275089336
Name:WALLGREN, BRANDI MICHELLE (MA, CF-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:MICHELLE
Last Name:WALLGREN
Suffix:
Gender:F
Credentials:MA, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 BELLA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-7850
Mailing Address - Country:US
Mailing Address - Phone:573-803-7434
Mailing Address - Fax:
Practice Address - Street 1:100 S GARRISON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2538
Practice Address - Country:US
Practice Address - Phone:314-340-5902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016026106235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist