Provider Demographics
NPI:1881986388
Name:WENTZEL, KEITH A
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:WENTZEL
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 1:5 DANA AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-5834
Mailing Address - Country:US
Mailing Address - Phone:207-240-6972
Mailing Address - Fax:877-789-6905
Practice Address - Street 1:79 MAIN ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-5811
Practice Address - Country:US
Practice Address - Phone:207-364-7981
Practice Address - Fax:877-789-6905
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4458101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health