Provider Demographics
NPI:1104568682
Name:WREASE, MICHAEL A II
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:WREASE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:WREASE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS
Mailing Address - Street 1:12904 ALFREDO APODACA
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-1000
Mailing Address - Country:US
Mailing Address - Phone:478-220-1824
Mailing Address - Fax:
Practice Address - Street 1:1101 E SCHUSTER AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4659
Practice Address - Country:US
Practice Address - Phone:915-544-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician