Provider Demographics
NPI:1326181199
Name:WANTLAND, CHERYL RAE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:RAE
Last Name:WANTLAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:WANTLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:387 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4302
Mailing Address - Country:US
Mailing Address - Phone:707-468-4185
Mailing Address - Fax:
Practice Address - Street 1:387 N OAK ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4302
Practice Address - Country:US
Practice Address - Phone:707-468-4185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS20517103T00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical