Provider Demographics
NPI:1770592107
Name:WANDAS, TERESA (PHD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WANDAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 FLEETWOOD AVE APT 4A
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-2864
Mailing Address - Country:US
Mailing Address - Phone:914-668-5767
Mailing Address - Fax:
Practice Address - Street 1:57 SAINT MARKS PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-7902
Practice Address - Country:US
Practice Address - Phone:212-982-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015846103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00015846Medicaid
NYVM6451Medicare ID - Type Unspecified