Provider Demographics
NPI:1790998136
Name:WENKE, DALE ALLEN (MA)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:ALLEN
Last Name:WENKE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N PROSPECT ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-1371
Mailing Address - Country:US
Mailing Address - Phone:740-321-3300
Mailing Address - Fax:740-321-3338
Practice Address - Street 1:130 N PROSPECT ST
Practice Address - Street 2:SUITE 12
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-1371
Practice Address - Country:US
Practice Address - Phone:740-321-3300
Practice Address - Fax:740-321-3338
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2034103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical