Healthcare Provider Details

I. General information

NPI: 1639196124
Provider Name (Legal Business Name): WANDA MAE DETTINGER LPC LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 A MACCORKLE AVE SW
CHARLESTON WV
25303
US

IV. Provider business mailing address

PO BOX 4009
CHARLESTON WV
25364-4009
US

V. Phone/Fax

Practice location:
  • Phone: 304-348-1288
  • Fax: 304-348-1262
Mailing address:
  • Phone: 304-348-1288
  • Fax: 304-348-1262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1564
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberAP00938675
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: