Provider Demographics
NPI:1952925711
Name:BIRD, WENDY GLISSON (CAC1)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:GLISSON
Last Name:BIRD
Suffix:
Gender:F
Credentials:CAC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52981 ROSEMARY CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-9450
Mailing Address - Country:US
Mailing Address - Phone:912-531-2928
Mailing Address - Fax:
Practice Address - Street 1:5 SW BROAD ST
Practice Address - Street 2:
Practice Address - City:METTER
Practice Address - State:GA
Practice Address - Zip Code:30439-4433
Practice Address - Country:US
Practice Address - Phone:912-515-5026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)