Provider Demographics
NPI:1104190511
Name:WHEETLEY, SANDRA KAY (LPC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:KAY
Last Name:WHEETLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 WEST BUSINESS HWY 60
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841
Mailing Address - Country:US
Mailing Address - Phone:573-624-6937
Mailing Address - Fax:
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5843
Practice Address - Country:US
Practice Address - Phone:573-624-6937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002735101YP2500X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities