Provider Demographics
NPI:1528596210
Name:WIGFALL, BRITIAN (BS)
Entity Type:Individual
Prefix:
First Name:BRITIAN
Middle Name:
Last Name:WIGFALL
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 SHARON CIR
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-2721
Mailing Address - Country:US
Mailing Address - Phone:229-939-0315
Mailing Address - Fax:
Practice Address - Street 1:940 GA HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2584
Practice Address - Country:US
Practice Address - Phone:478-957-9898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$Medicaid