Provider Demographics
NPI:1457718504
Name:MILLS, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:LEE-ANN
Other - Last Name:WEED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:239 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5979
Mailing Address - Country:US
Mailing Address - Phone:909-981-6121
Mailing Address - Fax:
Practice Address - Street 1:239 W 9TH ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5979
Practice Address - Country:US
Practice Address - Phone:909-981-6121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC13381214101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)