Provider Demographics
NPI:1477182541
Name:ROBERTS, WANDA JOY (MS)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:JOY
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3643 WALTON WAY EXT BLDG 4
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6677
Mailing Address - Country:US
Mailing Address - Phone:706-364-1404
Mailing Address - Fax:
Practice Address - Street 1:250 MILLEDGE RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-3577
Practice Address - Country:US
Practice Address - Phone:706-836-4710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty