Provider Demographics
NPI:1033167713
Name:WANDERSMAN, LOIS PALL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LOIS
Middle Name:PALL
Last Name:WANDERSMAN
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 1:1512 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2623
Mailing Address - Country:US
Mailing Address - Phone:803-252-5455
Mailing Address - Fax:803-252-5455
Practice Address - Street 1:1512 LAUREL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2623
Practice Address - Country:US
Practice Address - Phone:803-252-5455
Practice Address - Fax:803-252-5455
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC388103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical