Provider Demographics
NPI:1790167690
Name:YUSUF, WANDA (CMT)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:YUSUF
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 HERITAGE WAY
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:NC
Mailing Address - Zip Code:28326-6014
Mailing Address - Country:US
Mailing Address - Phone:803-873-7388
Mailing Address - Fax:888-965-9470
Practice Address - Street 1:429 PERSON ST STE 1-A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5737
Practice Address - Country:US
Practice Address - Phone:803-873-7388
Practice Address - Fax:888-965-9470
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17329225700000X
SC8500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC17329OtherNCBTMB
SC8500OtherSTATE LABOR AND LICENSING BOARD