Provider Demographics
NPI:1417618240
Name:WENTWORTH, TRISHA ANNE (MT-BC)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:ANNE
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 GREEN BAY RD # 2
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3026
Mailing Address - Country:US
Mailing Address - Phone:847-425-9708
Mailing Address - Fax:
Practice Address - Street 1:2130 GREEN BAY RD # 2
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3026
Practice Address - Country:US
Practice Address - Phone:847-425-9708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16573225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL473047364OtherBLUE CROSS BLUE SHIELD