Provider Demographics
NPI:1396148383
Name:WENTWORTH, BEVERLY (LAMFT)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 JAY LN
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7407
Mailing Address - Country:US
Mailing Address - Phone:651-253-4050
Mailing Address - Fax:651-426-3283
Practice Address - Street 1:1935 COUNTY ROAD B2 W STE 120
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2722
Practice Address - Country:US
Practice Address - Phone:651-253-4050
Practice Address - Fax:651-426-3283
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2934106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist