Provider Demographics
NPI:1245429448
Name:CERES, WANDA K (LPC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:K
Last Name:CERES
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 1:3210 FAIRHILL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3215
Mailing Address - Country:US
Mailing Address - Phone:919-256-0824
Mailing Address - Fax:
Practice Address - Street 1:725 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4833
Practice Address - Country:US
Practice Address - Phone:919-433-1491
Practice Address - Fax:919-433-1498
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6760101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103721Medicaid