Provider Demographics
NPI:1144686973
Name:WENDT, MICHAEL RONALD (LPC-IT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RONALD
Last Name:WENDT
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 S MATTHIAS ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3529
Mailing Address - Country:US
Mailing Address - Phone:920-730-9510
Mailing Address - Fax:
Practice Address - Street 1:W6144 AEROTECH DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-7503
Practice Address - Country:US
Practice Address - Phone:920-230-2065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2852-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional