Provider Demographics
NPI:1639196124
Name:DETTINGER, WANDA MAE (LPC LSW)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:MAE
Last Name:DETTINGER
Suffix:
Gender:F
Credentials:LPC LSW
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 4009
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25364-4009
Mailing Address - Country:US
Mailing Address - Phone:304-348-1288
Mailing Address - Fax:304-348-1262
Practice Address - Street 1:1418 A MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303
Practice Address - Country:US
Practice Address - Phone:304-348-1288
Practice Address - Fax:304-348-1262
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1564101YP2500X
WVAP00938675104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker