Provider Demographics
NPI:1942915590
Name:HORTON, WANDA L
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:HORTON
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 1:3566 OAK LIMB CV
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-3079
Mailing Address - Country:US
Mailing Address - Phone:901-216-7450
Mailing Address - Fax:
Practice Address - Street 1:2932 ALTRURIA RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-3862
Practice Address - Country:US
Practice Address - Phone:901-445-0998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5997101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health