Provider Demographics
NPI:1225374515
Name:WANLAND, BARBARA J (MED)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:J
Last Name:WANLAND
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2099 RIDGEVIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401
Mailing Address - Country:US
Mailing Address - Phone:928-718-4800
Mailing Address - Fax:928-718-5666
Practice Address - Street 1:2002 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4698
Practice Address - Country:US
Practice Address - Phone:928-718-4800
Practice Address - Fax:928-718-5666
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11872101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)