Provider Demographics
NPI:1760038475
Name:WAGENER, BRANDAL J (LMHC)
Entity Type:Individual
Prefix:MR
First Name:BRANDAL
Middle Name:J
Last Name:WAGENER
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 E 53RD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3627
Mailing Address - Country:US
Mailing Address - Phone:224-216-4209
Mailing Address - Fax:
Practice Address - Street 1:4620 E 53RD ST STE 200
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3627
Practice Address - Country:US
Practice Address - Phone:224-216-4209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-18
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA093843101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health