Provider Demographics
NPI:1073520722
Name:WENTWORTH, LAWRENCE DRAKE
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:DRAKE
Last Name:WENTWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LAWRENCE
Other - Middle Name:
Other - Last Name:WENTWORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:5721 MARLIN RD
Mailing Address - Street 2:STE 3100 6100 BLDG
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-5644
Mailing Address - Country:US
Mailing Address - Phone:423-648-2340
Mailing Address - Fax:423-499-9986
Practice Address - Street 1:5721 MARLIN RD
Practice Address - Street 2:STE 3100 6100 BLDG
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5644
Practice Address - Country:US
Practice Address - Phone:423-648-2340
Practice Address - Fax:423-499-9986
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3691042Medicaid
TN4077812OtherBCBS
TN3691042Medicare ID - Type Unspecified