Provider Demographics
NPI:1538627161
Name:WILSON, BREGETTA (MSCP)
Entity type:Individual
Prefix:
First Name:BREGETTA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2639 N PALMER ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2833
Mailing Address - Country:US
Mailing Address - Phone:414-750-0876
Mailing Address - Fax:
Practice Address - Street 1:2222 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-2262
Practice Address - Country:US
Practice Address - Phone:414-939-9252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-02
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4288-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health