Provider Demographics
NPI:1528394772
Name:WENTZ, COREY (MS, LPC, LAT)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:WENTZ
Suffix:
Gender:F
Credentials:MS, LPC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82602-0552
Mailing Address - Country:US
Mailing Address - Phone:307-797-4683
Mailing Address - Fax:307-337-3705
Practice Address - Street 1:1301 S WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2936
Practice Address - Country:US
Practice Address - Phone:307-472-5433
Practice Address - Fax:307-337-3705
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT 286101YA0400X
WYLPC 817101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)