Provider Demographics
NPI:1821796020
Name:MCINNIS, WANDA (MA LPC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11713 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2400
Mailing Address - Country:US
Mailing Address - Phone:757-503-2819
Mailing Address - Fax:757-369-1981
Practice Address - Street 1:11713 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2400
Practice Address - Country:US
Practice Address - Phone:757-503-2819
Practice Address - Fax:757-369-1981
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional