Provider Demographics
NPI:1508521261
Name:PHIPPS, WANDA SHAVON (MSP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:SHAVON
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26371 BARRANQUILLA AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-5723
Mailing Address - Country:US
Mailing Address - Phone:941-380-8957
Mailing Address - Fax:
Practice Address - Street 1:26371 BARRANQUILLA AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-5723
Practice Address - Country:US
Practice Address - Phone:941-380-8957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor