Provider Demographics
NPI:1568046738
Name:WANCY, NELCIE
Entity Type:Individual
Prefix:
First Name:NELCIE
Middle Name:
Last Name:WANCY
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 1:2290 10TH AVE N STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6609
Mailing Address - Country:US
Mailing Address - Phone:610-763-7661
Mailing Address - Fax:
Practice Address - Street 1:2290 10TH AVE N STE 105
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-6609
Practice Address - Country:US
Practice Address - Phone:610-763-7661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-164591106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician