Provider Demographics
NPI:1063178291
Name:GOTHARD, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GOTHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 COUNTY ROAD 124
Mailing Address - Street 2:
Mailing Address - City:JEMISON
Mailing Address - State:AL
Mailing Address - Zip Code:35085-4025
Mailing Address - Country:US
Mailing Address - Phone:205-955-0009
Mailing Address - Fax:
Practice Address - Street 1:808 LAY DAM RD
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-2943
Practice Address - Country:US
Practice Address - Phone:205-280-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3499101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor