Basic Information
Provider Information | |||||||||
NPI: | 1578237640 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAKEMAN | ||||||||
FirstName: | CHERYL | ||||||||
MiddleName: | AMANDA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JENKINS | ||||||||
OtherFirstName: | CHERYL | ||||||||
OtherMiddleName: | AMANDA | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1978 | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218021978 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107491015 | ||||||||
FaxNumber: | 4107490654 | ||||||||
Practice Location | |||||||||
Address1: | 12145 ELM ST | ||||||||
Address2: |   | ||||||||
City: | PRINCESS ANNE | ||||||||
State: | MD | ||||||||
PostalCode: | 218531358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106512204 | ||||||||
FaxNumber: | 4106510790 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2021 | ||||||||
LastUpdateDate: | 08/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 27434 | MD | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 119591300 | 05 | MD |   | MEDICAID |