Active NPI
Bradley Mark Wolgast
- Counseling Psychologist
- Media, PA
National Provider Identifier
1457012767
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Counseling Psychologist
- License
- PS015452
- Practice address
- 221 N Olive St
Media, PA 19063-3250 - Phone
- (484) 442-0849
- NPI assigned
- Jan 8, 2022
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counseling Psychologist | 103TC1900X | B10000802 | DE | |
| Counseling Psychologist | 103TC1900X | PS015452 | PA | Primary |
Addresses
Primary practice location
221 N Olive St
Media, PA 19063-3250
Mailing address
221 N Olive St
Media, PA 19063-3250
Phone (484) 442-0849
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Nov 29, 2022 through Nov 29, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| B10000802 | DE | MD | Counseling Psychologist |
| PS015452 | PA | MD | Counseling Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1641600000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1641600000000",
"number": "1457012767",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "221 N OLIVE ST",
"city": "MEDIA",
"state": "PA",
"postal_code": "190633250",
"telephone_number": "484-442-0849"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "221 N OLIVE ST",
"city": "MEDIA",
"state": "PA",
"postal_code": "190633250",
"telephone_number": "484-442-0849"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WOLGAST",
"first_name": "BRADLEY",
"middle_name": "MARK",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2022-01-08",
"last_updated": "2022-01-08",
"certification_date": "2022-01-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC1900X",
"taxonomy_group": "",
"desc": "Psychologist, Counseling",
"state": "DE",
"license": "B10000802",
"primary": false
},
{
"code": "103TC1900X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Psychologist, Counseling",
"state": "PA",
"license": "PS015452",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Media, PA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.