Basic Information
| Provider Information | |||||||||
| NPI: | 1124039847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCENTYRE | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142932594 | ||||||||
| FaxNumber: | 6142934487 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 OLENTANGY RIVER RD FL 1 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432123117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143668700 | ||||||||
| FaxNumber: | 6142937264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3889 | OH | N | Behavioral Health & Social Service Providers | Psychologist | 103TR0400X | 3889 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0805810 | 05 | OH | MEDICAID |