Provider Demographics
NPI:1891325197
Name:MOBLEY, WANDA J
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:J
Last Name:MOBLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CASKEY LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-2758
Mailing Address - Country:US
Mailing Address - Phone:803-718-9755
Mailing Address - Fax:
Practice Address - Street 1:108 CASKEY LN
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2758
Practice Address - Country:US
Practice Address - Phone:803-718-9755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO139391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty