Basic Information
| Provider Information | |||||||||
| NPI: | 1023160546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REBERT | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAGNOLI | ||||||||
| OtherFirstName: | WENDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2020 PEACHTREE RD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043507323 | ||||||||
| FaxNumber: | 4043507694 | ||||||||
| Practice Location | |||||||||
| Address1: | 1109 SPRING DR | ||||||||
| Address2: | |||||||||
| City: | OPELIKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368015345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347452760 | ||||||||
| FaxNumber: | 3347457998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 01/31/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY002491 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 550 | AL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 890011270 | 05 | AL | MEDICAID |