Provider Demographics
NPI:1487780292
Name:WILLIAMS, BRENDA WIEGAND (PHD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:WIEGAND
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3800 S NATIONAL AVE STE 770
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5283
Practice Address - Country:US
Practice Address - Phone:417-269-6891
Practice Address - Fax:417-269-5595
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS702103T00000X
MOR0440103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499679207Medicaid
MO132439OtherBLUE SHIELD