Provider Demographics
NPI:1376786459
Name:BRENT WHEELER
Entity Type:Organization
Organization Name:BRENT WHEELER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC, LSSP, LPA
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:512-786-0467
Mailing Address - Street 1:2300 E. 8TH ST.
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702
Mailing Address - Country:US
Mailing Address - Phone:512-512-7860
Mailing Address - Fax:
Practice Address - Street 1:1907 N. LAMAR BLVD
Practice Address - Street 2:SUITE 354
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-786-0467
Practice Address - Fax:254-519-3464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15744101YM0800X
101YP2500X, 103TS0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5301LCOtherBLUE CROSS/BLUE SHIELD