Provider Demographics
NPI:1588838734
Name:WENTZ, STACY (DTHS)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WENTZ
Suffix:
Gender:F
Credentials:DTHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-326-2911
Mailing Address - Fax:217-344-8047
Practice Address - Street 1:611 W PARK
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-326-2911
Practice Address - Fax:217-344-8047
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203OtherBLUE CROSS
IL4117OtherHEALTH ALLIANCE
IL113326OtherHEALTHLINK
IL7216OtherPERSONAL CARE
IL4117OtherHEALTH ALLIANCE