Provider Demographics
NPI:1134464894
Name:WENNIK, TAFF (LPC)
Entity Type:Individual
Prefix:
First Name:TAFF
Middle Name:
Last Name:WENNIK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 ALTAMESA BLVD
Mailing Address - Street 2:SUITE 1G1C
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-6112
Mailing Address - Country:US
Mailing Address - Phone:817-584-7132
Mailing Address - Fax:
Practice Address - Street 1:4701 ALTAMESA BLVD
Practice Address - Street 2:SUITE 1G1C
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-6112
Practice Address - Country:US
Practice Address - Phone:817-584-7132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69958101YP2500X
CO6267101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional