Provider Demographics
NPI:1457497679
Name:WENGER, KATHY (LMHC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:WENGER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 LINCOLNWAY E
Mailing Address - Street 2:SUITE 700
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-3220
Mailing Address - Country:US
Mailing Address - Phone:574-232-2255
Mailing Address - Fax:574-232-8968
Practice Address - Street 1:611 LINCOLNWAY E
Practice Address - Street 2:SUITE 700
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-3220
Practice Address - Country:US
Practice Address - Phone:574-232-2255
Practice Address - Fax:574-232-8968
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001807A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000492651OtherANTHEM
IN000000492651OtherUNICARE
IN000000492651OtherUNICARE
IN148460AMedicare PIN