Provider Demographics
NPI:1790734556
Name:EUBANK, WANDA (LCSW, RN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:EUBANK
Suffix:
Gender:F
Credentials:LCSW, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUWANNEE TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7956
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-842-5268
Practice Address - Street 1:380 SUWANNEE TRAIL STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1055267163W00000X
KY18691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100287840Medicaid
KY30604011Medicaid