Provider Demographics
NPI:1669691176
Name:WENTWORTH, CORLISS (COUNSELOR)
Entity type:Individual
Prefix:
First Name:CORLISS
Middle Name:
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:MRS
Other - First Name:CORLISS
Other - Middle Name:
Other - Last Name:WENTWORTH-THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CP00005457
Mailing Address - Street 1:2009 NE 117TH ST
Mailing Address - Street 2:101
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-4022
Mailing Address - Country:US
Mailing Address - Phone:360-566-9112
Mailing Address - Fax:360-566-9133
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD # 101
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3713
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:360-397-8450
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005457101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)