Provider Demographics
NPI:1487896684
Name:WINGARD, BRIAN ROBERT (MA)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:ROBERT
Last Name:WINGARD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 BREVARD AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7849
Mailing Address - Country:US
Mailing Address - Phone:321-433-1111
Mailing Address - Fax:321-252-0425
Practice Address - Street 1:640 BREVARD AVE STE 104
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7849
Practice Address - Country:US
Practice Address - Phone:321-433-1111
Practice Address - Fax:321-252-0425
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3367225200000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant