Provider Demographics
NPI:1578615449
Name:ECKERSLEY, WANDA RUTH (LPC)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:RUTH
Last Name:ECKERSLEY
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:PO BOX 924
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77549-0924
Mailing Address - Country:US
Mailing Address - Phone:281-992-3300
Mailing Address - Fax:281-996-0261
Practice Address - Street 1:2006 BROADWAY ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5564
Practice Address - Country:US
Practice Address - Phone:281-992-3300
Practice Address - Fax:281-996-0261
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17422101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1490393-02Medicaid
TX6070 LCOtherBLUE CROSS BLUE SHIELD