Provider Demographics
NPI:1639484652
Name:WILLIAMS, WANDA LACAROL (MASTER'S SOCIAL WORK)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:LACAROL
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MASTER'S SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1939
Mailing Address - Country:US
Mailing Address - Phone:414-445-1400
Mailing Address - Fax:414-445-1406
Practice Address - Street 1:6570 N 80TH ST
Practice Address - Street 2:208#
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-5579
Practice Address - Country:US
Practice Address - Phone:414-760-8653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15735-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1160Medicaid