Provider Demographics
NPI:1861775827
Name:FRASER, WANDA JEAN (BA)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:JEAN
Last Name:FRASER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MS
Other - First Name:WANDA
Other - Middle Name:JEAN
Other - Last Name:FRASER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11 UNION ST S
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-5059
Mailing Address - Country:US
Mailing Address - Phone:304-960-9348
Mailing Address - Fax:
Practice Address - Street 1:11 UNION ST S STE 207
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1004
Practice Address - Country:US
Practice Address - Phone:704-837-0084
Practice Address - Fax:704-956-2325
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCCSI20285101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)