Healthcare Provider Details

I. General information

NPI: 1356035463
Provider Name (Legal Business Name): DR. WANDA D DUNMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10418 WHITE PEACOCK PL
RIVERVIEW FL
33578-5815
US

IV. Provider business mailing address

10418 WHITE PEACOCK PL
RIVERVIEW FL
33578-5815
US

V. Phone/Fax

Practice location:
  • Phone: 203-435-8051
  • Fax:
Mailing address:
  • Phone: 203-435-8051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: