Provider Demographics
NPI:1295159192
Name:BANFORD, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:BANFORD
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 1:9340 RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-5002
Mailing Address - Country:US
Mailing Address - Phone:313-345-4310
Mailing Address - Fax:
Practice Address - Street 1:15941 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4123
Practice Address - Country:US
Practice Address - Phone:313-345-4310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator