Provider Demographics
NPI:1114209152
Name:WENZEL, MEAGHAN FAITH
Entity Type:Individual
Prefix:
First Name:MEAGHAN
Middle Name:FAITH
Last Name:WENZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONRAD
Other - Middle Name:FAITH
Other - Last Name:WENZEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2116 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2116 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2310
Practice Address - Country:US
Practice Address - Phone:510-899-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8133Medicaid