Healthcare Provider Details

I. General information

NPI: 1184826901
Provider Name (Legal Business Name): WANDA MARIE HEATH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 10/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 SOUTH AVE SE
MARIETTA GA
30060-2358
US

IV. Provider business mailing address

6162 INDIAN WOOD CIR SE
MABLETON GA
30126-2965
US

V. Phone/Fax

Practice location:
  • Phone: 404-312-8267
  • Fax:
Mailing address:
  • Phone: 404-696-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY002823
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: