Provider Demographics
NPI:1972624971
Name:WENGER, DOUGLAS (LICSW)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:WENGER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:DOUGLAS
Other - Middle Name:
Other - Last Name:WENGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:WILMOT
Mailing Address - State:NH
Mailing Address - Zip Code:03287-0012
Mailing Address - Country:US
Mailing Address - Phone:802-230-7760
Mailing Address - Fax:
Practice Address - Street 1:136 STONE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:WILMOT
Practice Address - State:NH
Practice Address - Zip Code:03287-4626
Practice Address - Country:US
Practice Address - Phone:802-230-7760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099238971041C0700X
NH25371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7706638Y0NH01OtherANTHEM