Basic Information
| Provider Information | |||||||||
| NPI: | 1891118832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLOUD | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2485 MATTHEW CIR | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955037317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303685427 | ||||||||
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| Practice Location | |||||||||
| Address1: | 720 WOOD ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072682990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2014 | ||||||||
| LastUpdateDate: | 01/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 03-086159 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 03-086159 | 01 | CA | BOARD FOR CERTIFICATION OF ADDICTION SPECIALIST -CAARR | OTHER |