Provider Demographics
NPI:1962164368
Name:TALIAFERRO, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:TALIAFERRO
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 1:913 COLLENBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-4418
Mailing Address - Country:US
Mailing Address - Phone:267-970-1052
Mailing Address - Fax:
Practice Address - Street 1:913 COLLENBROOK AVE
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-4418
Practice Address - Country:US
Practice Address - Phone:267-970-1052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC012497101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1699048173Medicaid