Provider Demographics
NPI:1376381806
Name:WIEDRICH, BRENNAN CHRISTOPHER (LCMHC-A, CRC)
Entity type:Individual
Prefix:
First Name:BRENNAN
Middle Name:CHRISTOPHER
Last Name:WIEDRICH
Suffix:
Gender:M
Credentials:LCMHC-A, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 OKELLY ST APT B
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-5345
Mailing Address - Country:US
Mailing Address - Phone:206-219-9243
Mailing Address - Fax:
Practice Address - Street 1:5171 GLENWOOD AVE STE 211
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-3266
Practice Address - Country:US
Practice Address - Phone:206-219-9243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20286101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health