Provider Demographics
NPI:1497104699
Name:WILEY, BRENDA LAGUNAS (PHD, LP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LAGUNAS
Last Name:WILEY
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:LAGUNAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1725 S NAPERVILLE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-5855
Mailing Address - Country:US
Mailing Address - Phone:815-469-1500
Mailing Address - Fax:
Practice Address - Street 1:1725 S NAPERVILLE RD STE 110
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-5855
Practice Address - Country:US
Practice Address - Phone:630-509-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010338103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490059317Medicaid