Basic Information
| Provider Information | |||||||||
| NPI: | 1598737884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONACOTT | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D., HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 KALISA WAY STE 101 | ||||||||
| Address2: | |||||||||
| City: | PARAMUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076523508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889486789 | ||||||||
| FaxNumber: | 8773453501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1443 CORPORATE WAY | ||||||||
| Address2: | |||||||||
| City: | SEYMOUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125224341 | ||||||||
| FaxNumber: | 8125227910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20041777A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200401020A | 05 | IN | MEDICAID | 000000209033 | 01 | IN | ANTHEM PIN | OTHER |