Provider Demographics
NPI:1679894653
Name:DATLOW, WENDY SUSAN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:SUSAN
Last Name:DATLOW
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17824 33RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-4017
Mailing Address - Country:US
Mailing Address - Phone:215-528-7344
Mailing Address - Fax:
Practice Address - Street 1:12026 GOSHEN AVE
Practice Address - Street 2:APT. 8
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6326
Practice Address - Country:US
Practice Address - Phone:215-528-7344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WALW609071341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker