Provider Demographics
NPI:1336251545
Name:DEVAUGHN, WANDA HAZEL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:HAZEL
Last Name:DEVAUGHN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:WANDA
Other - Middle Name:HAZEL
Other - Last Name:DEVAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:317 ALEXANDER ST SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2077
Mailing Address - Country:US
Mailing Address - Phone:770-425-4488
Mailing Address - Fax:770-425-8862
Practice Address - Street 1:317 ALEXANDER ST SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2077
Practice Address - Country:US
Practice Address - Phone:770-425-4488
Practice Address - Fax:770-425-8862
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBBCKMedicare ID - Type Unspecified