Healthcare Provider Details

I. General information

NPI: 1346350238
Provider Name (Legal Business Name): TAMMY LYNNE WANAMAKER M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WILLIAMS DR SUITE 1
GEORGETOWN TX
78628-4109
US

IV. Provider business mailing address

1101 WILLIAMS DR SUITE 1
GEORGETOWN TX
78628-4109
US

V. Phone/Fax

Practice location:
  • Phone: 512-863-9056
  • Fax: 512-233-1099
Mailing address:
  • Phone: 512-863-9056
  • Fax: 512-233-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC 05402
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number361
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: