Provider Demographics
NPI:1972032639
Name:WENZEL, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:WENZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13495 W FOUNTAIN DR APT 203
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3986
Mailing Address - Country:US
Mailing Address - Phone:414-303-1919
Mailing Address - Fax:
Practice Address - Street 1:1610 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3604
Practice Address - Country:US
Practice Address - Phone:414-939-7556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18050130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)