Provider Demographics
NPI:1205158979
Name:AUSTIN, WANDA GAYLE (LMHC, NCC)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:GAYLE
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 CARA DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-1027
Mailing Address - Country:US
Mailing Address - Phone:727-586-4741
Mailing Address - Fax:727-585-8061
Practice Address - Street 1:11599 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-3205
Practice Address - Country:US
Practice Address - Phone:727-418-9296
Practice Address - Fax:727-585-8061
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health