Provider Demographics
NPI:1023891603
Name:BOSTIC, WENDALYN (LCSW)
Entity type:Individual
Prefix:
First Name:WENDALYN
Middle Name:
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 JOHN RAMSEY RD
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-9124
Mailing Address - Country:US
Mailing Address - Phone:601-528-1908
Mailing Address - Fax:
Practice Address - Street 1:16 JOHN RAMSEY RD
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-9124
Practice Address - Country:US
Practice Address - Phone:601-582-1908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC104121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical