Provider Demographics
NPI:1912058488
Name:HANEVOLD, WENDY ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:WENDY
Middle Name:ANN
Last Name:HANEVOLD
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 1:1235 PARKMONT DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1741
Mailing Address - Country:US
Mailing Address - Phone:404-325-1614
Mailing Address - Fax:404-325-1615
Practice Address - Street 1:555 SUN VALLEY DR
Practice Address - Street 2:SUITE M-1
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5612
Practice Address - Country:US
Practice Address - Phone:404-325-1614
Practice Address - Fax:404-325-1615
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1574103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist