Provider Demographics
NPI:1326424078
Name:CODY, WENDY PANDORA
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:PANDORA
Last Name:CODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11253 SOMERSET AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1128
Mailing Address - Country:US
Mailing Address - Phone:313-530-3411
Mailing Address - Fax:313-579-9172
Practice Address - Street 1:11253 SOMERSET AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1128
Practice Address - Country:US
Practice Address - Phone:313-530-3411
Practice Address - Fax:313-579-9172
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014781103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical