Provider Demographics
NPI:1003964453
Name:BUCHANAN, WANDA J (ST)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:J
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W PINHOOK RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2131
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-233-5764
Practice Address - Street 1:RR 2 BOX 169-G
Practice Address - Street 2:GRAYROCK PROFESSIONAL PARK
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9316
Practice Address - Country:US
Practice Address - Phone:304-645-1706
Practice Address - Fax:304-645-4085
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006723Medicaid