Provider Demographics
NPI:1700504792
Name:WENSLEY, SAMUEL CHRISTIAN
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:CHRISTIAN
Last Name:WENSLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46792 DOUBLETREE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1683
Mailing Address - Country:US
Mailing Address - Phone:734-707-6443
Mailing Address - Fax:
Practice Address - Street 1:1511 WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-3122
Practice Address - Country:US
Practice Address - Phone:734-707-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851115259104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6851115259OtherDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS