Provider Demographics
NPI:1902926991
Name:GHOLSTON, WANDA LEWIS (MA LBSW)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LEWIS
Last Name:GHOLSTON
Suffix:
Gender:F
Credentials:MA LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-1157
Mailing Address - Country:US
Mailing Address - Phone:256-426-1856
Mailing Address - Fax:
Practice Address - Street 1:4520 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE B-100
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-1619
Practice Address - Country:US
Practice Address - Phone:334-270-3181
Practice Address - Fax:334-270-5805
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1378B104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker