Provider Demographics
NPI:1598737884
Name:WONACOTT, NANCY (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:WONACOTT
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KALISA WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3508
Mailing Address - Country:US
Mailing Address - Phone:888-948-6789
Mailing Address - Fax:877-345-3501
Practice Address - Street 1:1443 CORPORATE WAY
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274
Practice Address - Country:US
Practice Address - Phone:812-522-4341
Practice Address - Fax:812-522-7910
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041777A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200401020AMedicaid
IN000000209033OtherANTHEM PIN
IN200401020AMedicaid