Provider Demographics
NPI:1619208048
Name:WAN, LI
Entity Type:Individual
Prefix:
First Name:LI
Middle Name:
Last Name:WAN
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 1:1 BEAR PL UNIT 97334
Mailing Address - Street 2:DEPT. OF PSYCHOLOGY
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76798-7334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BEAR PL UNIT 97334
Practice Address - Street 2:DEPT. OF PSYCHOLOGY
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76798-7334
Practice Address - Country:US
Practice Address - Phone:254-710-2245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
ZZ19994211042230176010103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst