Provider Demographics
NPI:1184649378
Name:DENNIS, WANDA DENISE (PHD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:DENISE
Last Name:DENNIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:DENNIS
Other - Last Name:JOUBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1758 BRIDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3280
Mailing Address - Country:US
Mailing Address - Phone:248-872-5227
Mailing Address - Fax:
Practice Address - Street 1:30100 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4514
Practice Address - Country:US
Practice Address - Phone:248-443-7021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003531103TC0700X
MI6301011636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIVALUEOPTIONSOtherBCBC, BCN
MI2055092OtherCIGNA
MIVALUEOPTIONSOtherBCBC, BCN
MI2055092OtherCIGNA