Provider Demographics
NPI:1568675320
Name:WENTWORTH, COLLEEN BARBARA (MA LCMHC)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:BARBARA
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:MA LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COTTON PL
Mailing Address - Street 2:PO BOX 192
Mailing Address - City:MONT VERNON
Mailing Address - State:NH
Mailing Address - Zip Code:03057-1405
Mailing Address - Country:US
Mailing Address - Phone:603-673-4650
Mailing Address - Fax:
Practice Address - Street 1:172 KINSLEY ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3648
Practice Address - Country:US
Practice Address - Phone:603-882-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH646101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30424790Medicaid