Provider Demographics
NPI:1144342478
Name:WANDA G. FOX
Entity type:Organization
Organization Name:WANDA G. FOX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:G
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:LSW,MSW
Authorized Official - Phone:208-265-0745
Mailing Address - Street 1:819 HWY 2 PIONEER SQ. 204
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0000
Mailing Address - Country:US
Mailing Address - Phone:208-265-0745
Mailing Address - Fax:208-255-1543
Practice Address - Street 1:819 HWY 2 PIONEER SQ. 204
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-0000
Practice Address - Country:US
Practice Address - Phone:208-265-0745
Practice Address - Fax:208-255-1543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-2722251S00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8068102Medicaid
ID8068389Medicaid