Provider Demographics
NPI:1912198128
Name:WENNERHOLM, WILLIAM C (LCSW)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:WENNERHOLM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 WILLOW CREEK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1124
Mailing Address - Country:US
Mailing Address - Phone:928-771-9424
Mailing Address - Fax:928-717-1634
Practice Address - Street 1:1660 WILLOW CREEK RD
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1124
Practice Address - Country:US
Practice Address - Phone:928-771-9424
Practice Address - Fax:928-717-1634
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ LCSW 1943101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health