Individual provider · NPI-1

Wallace Edward Brandies Jr., CSAC ICS

Counselor, Addiction (Substance Use Disorder) · Racine, WI

NPI number1811595671
StatusActive
Last updated in NPPESOct 14, 2020

Details

NPI
1811595671
Entity type
Individual (NPI-1)
Name
Mr. Wallace Edward Brandies Jr.
Credential
CSAC ICS
Sex
Male
Sole proprietor
No
Enumeration date
Oct 14, 2020
Certification date
Oct 14, 2020
Last updated
Oct 14, 2020

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
101YA0400X Counselor, Addiction (Substance Use Disorder)15295-132WIYes

Practice location

1717 Taylor Ave
Racine, WI 53403-2405

Phone 262-638-6635 · Fax 262-638-6540

Mailing address

1717 Taylor Ave
Racine, WI 53403-2405

Phone 262-638-6635 · Fax 262-638-6540

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