Provider Demographics
NPI:1487921045
Name:WILBERG, BRADLEY ALEXANDER (BCABA)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:ALEXANDER
Last Name:WILBERG
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 KING ST
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7621
Mailing Address - Country:US
Mailing Address - Phone:321-633-5511
Mailing Address - Fax:321-208-7441
Practice Address - Street 1:453 KING ST
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7621
Practice Address - Country:US
Practice Address - Phone:321-633-5511
Practice Address - Fax:321-208-7441
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-16-17842106S00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician