Provider Demographics
NPI:1538993795
Name:CHAMPAGNE-WAHLBERG, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:CHAMPAGNE-WAHLBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39959 GOLFERS DR
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-2920
Mailing Address - Country:US
Mailing Address - Phone:661-305-6109
Mailing Address - Fax:
Practice Address - Street 1:27225 CAMP PLENTY RD STE 7
Practice Address - Street 2:
Practice Address - City:CANYON CNTRY
Practice Address - State:CA
Practice Address - Zip Code:91351-2654
Practice Address - Country:US
Practice Address - Phone:818-927-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC16229101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional