Provider Demographics
NPI:1245413913
Name:WENTZ, PAMELA JEANNE (LSW)
Entity Type:Individual
Prefix:MISS
First Name:PAMELA
Middle Name:JEANNE
Last Name:WENTZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S BROADWAY
Mailing Address - Street 2:SUITE 18
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-857-8500
Mailing Address - Fax:701-857-8555
Practice Address - Street 1:1237 W DIVIDE AVE STE 5
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1208
Practice Address - Country:US
Practice Address - Phone:701-328-8745
Practice Address - Fax:701-857-8555
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND079317171M00000X
ND3929104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054517Medicaid