Provider Demographics
NPI:1790447001
Name:WENTZ, ANTHONY M (LAC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:M
Last Name:WENTZ
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 EAST BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-222-0386
Mailing Address - Fax:701-255-4891
Practice Address - Street 1:7448 68TH AVE. NE
Practice Address - Street 2:
Practice Address - City:CANDO
Practice Address - State:ND
Practice Address - Zip Code:58324
Practice Address - Country:US
Practice Address - Phone:701-968-4056
Practice Address - Fax:701-968-4456
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1914101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)