Provider Demographics
NPI:1164524237
Name:WENTZ, DEBRA JEAN (MSW LCSW CADCIII)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:WENTZ
Suffix:
Gender:F
Credentials:MSW LCSW CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 CALUMET DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-3839
Mailing Address - Country:US
Mailing Address - Phone:920-457-4461
Mailing Address - Fax:920-459-1483
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:920-459-1483
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1348101YA0400X
WI69211231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39331400Medicaid
WI84282Medicare ID - Type Unspecified