Provider Demographics
NPI:1669490025
Name:WANTZ, RICHARD A (EDD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:WANTZ
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 LEMCKE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6727
Mailing Address - Country:US
Mailing Address - Phone:937-657-7655
Mailing Address - Fax:937-775-2042
Practice Address - Street 1:1411 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2658
Practice Address - Country:US
Practice Address - Phone:937-426-2686
Practice Address - Fax:937-426-2686
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4517103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2000168Medicaid
OH2000168Medicaid