Provider Demographics
NPI:1962811620
Name:LAW, WANDA M (MASTERS OF EDUCATION)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:M
Last Name:LAW
Suffix:
Gender:F
Credentials:MASTERS OF EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32053-0180
Mailing Address - Country:US
Mailing Address - Phone:386-938-2097
Mailing Address - Fax:386-938-2636
Practice Address - Street 1:7150 NW 22ND DRIVE
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:FL
Practice Address - Zip Code:32053
Practice Address - Country:US
Practice Address - Phone:229-506-3999
Practice Address - Fax:386-487-0366
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management