Provider Demographics
NPI:1629371091
Name:FOX-WENTZ, NORA ADESSA (MASTER'S LTD PSYCHO)
Entity Type:Individual
Prefix:MRS
First Name:NORA
Middle Name:ADESSA
Last Name:FOX-WENTZ
Suffix:
Gender:F
Credentials:MASTER'S LTD PSYCHO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 249
Mailing Address - Street 2:801 HAZEN ST.
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0249
Mailing Address - Country:US
Mailing Address - Phone:269-657-5574
Mailing Address - Fax:269-657-6523
Practice Address - Street 1:57418 CR. 681
Practice Address - Street 2:SUITE C
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057
Practice Address - Country:US
Practice Address - Phone:269-621-6251
Practice Address - Fax:269-621-6044
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014447103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist