Provider Demographics
NPI:1457012767
Name:WOLGAST, BRADLEY MARK
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:MARK
Last Name:WOLGAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3250
Mailing Address - Country:US
Mailing Address - Phone:484-442-0849
Mailing Address - Fax:
Practice Address - Street 1:221 N OLIVE ST
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3250
Practice Address - Country:US
Practice Address - Phone:484-442-0849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-08
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10000802103TC1900X
PAPS015452103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling