Provider Demographics
NPI:1306827191
Name:WENTWORTH AND ASSOCIATES PC
Entity Type:Organization
Organization Name:WENTWORTH AND ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WENTWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:586-997-3153
Mailing Address - Street 1:11111 HALL RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-5711
Mailing Address - Country:US
Mailing Address - Phone:586-997-3153
Mailing Address - Fax:586-997-4956
Practice Address - Street 1:11111 HALL RD
Practice Address - Street 2:SUITE 400
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5711
Practice Address - Country:US
Practice Address - Phone:586-997-3153
Practice Address - Fax:586-997-4956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007769103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS08282Medicare UPIN
MI0P03030Medicare PIN