Provider Demographics
NPI:1639434152
Name:BEAVER, WONDA BULLOCK (NCC, LCAS, LPC-A)
Entity Type:Individual
Prefix:
First Name:WONDA
Middle Name:BULLOCK
Last Name:BEAVER
Suffix:
Gender:F
Credentials:NCC, LCAS, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 DUCK POND CT
Mailing Address - Street 2:PO BOX 11011
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-6096
Mailing Address - Country:US
Mailing Address - Phone:919-451-2480
Mailing Address - Fax:
Practice Address - Street 1:9 DUCK POND CT
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-6096
Practice Address - Country:US
Practice Address - Phone:919-451-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)