Provider Demographics
NPI:1780853382
Name:PRIDDY, WANDA W (LCSW)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:W
Last Name:PRIDDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:E
Other - Last Name:WAHNEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:301 N 2ND ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-2012
Practice Address - Country:US
Practice Address - Phone:918-642-3515
Practice Address - Fax:918-642-3519
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK33831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3383OtherSTATE LICENSE
OK3383OtherSTATE LICENSE