Provider Demographics
NPI:1649649245
Name:WAILES, DANICA (PSYD)
Entity type:Individual
Prefix:DR
First Name:DANICA
Middle Name:
Last Name:WAILES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 EXPRESSWAY LN STE 240
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7122
Mailing Address - Country:US
Mailing Address - Phone:417-597-4309
Mailing Address - Fax:
Practice Address - Street 1:192 EXPRESSWAY LN STE 240
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7122
Practice Address - Country:US
Practice Address - Phone:417-597-4309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015033117103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical