Provider Demographics
NPI:1922246453
Name:WENTWORTH, AUDREY ELAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ELAINE
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:BABCOCK-WENTWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2650 BAHIA VISTA ST
Mailing Address - Street 2:#105
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2611
Mailing Address - Country:US
Mailing Address - Phone:941-316-0390
Mailing Address - Fax:941-951-2658
Practice Address - Street 1:2650 BAHIA VISTA ST
Practice Address - Street 2:#105
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2611
Practice Address - Country:US
Practice Address - Phone:941-316-0390
Practice Address - Fax:941-951-2658
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW1569104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
K7732Medicare PIN