Provider Demographics
NPI:1003924598
Name:WENTWORTH-ROHR, LISA (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WENTWORTH-ROHR
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:RADHE
Other - Middle Name:
Other - Last Name:ROHR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:11121 W NORTH AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2233
Mailing Address - Country:US
Mailing Address - Phone:262-780-9788
Mailing Address - Fax:414-443-2719
Practice Address - Street 1:11121 W NORTH AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2233
Practice Address - Country:US
Practice Address - Phone:262-780-9788
Practice Address - Fax:414-443-2719
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2008-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30691231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43579900Medicaid