Provider Demographics
NPI:1336491653
Name:COLLAZO, WANDA IVETTE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:IVETTE
Last Name:COLLAZO
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 1:316 SHAWCROFT RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-2934
Mailing Address - Country:US
Mailing Address - Phone:910-424-2020
Mailing Address - Fax:910-424-8435
Practice Address - Street 1:590 CEDAR CREEK RD
Practice Address - Street 2:SUITE 110
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-6559
Practice Address - Country:US
Practice Address - Phone:910-424-2020
Practice Address - Fax:910-424-8435
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9258101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health