Provider Demographics
NPI:1255012795
Name:WIGFALL, BRELAND M (LCSWA)
Entity type:Individual
Prefix:
First Name:BRELAND
Middle Name:M
Last Name:WIGFALL
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 EBENEZER RD STE 225
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1119
Mailing Address - Country:US
Mailing Address - Phone:803-329-9639
Mailing Address - Fax:
Practice Address - Street 1:1721 EBENEZER RD STE 225
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1119
Practice Address - Country:US
Practice Address - Phone:803-329-9639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0148071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical