Provider Demographics
NPI:1992045603
Name:WENTWORTH, KONNIE
Entity Type:Individual
Prefix:
First Name:KONNIE
Middle Name:
Last Name:WENTWORTH
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 1:6301 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6103
Mailing Address - Country:US
Mailing Address - Phone:918-289-0550
Mailing Address - Fax:
Practice Address - Street 1:6301 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6103
Practice Address - Country:US
Practice Address - Phone:918-289-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health