Provider Demographics
NPI:1356735468
Name:WENTWORTH AND ASSOCIATES, P.C.
Entity type:Organization
Organization Name:WENTWORTH AND ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WENTWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-997-3153
Mailing Address - Street 1:28871 ALINE DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2690
Mailing Address - Country:US
Mailing Address - Phone:586-307-2137
Mailing Address - Fax:
Practice Address - Street 1:11111 HALL RD STE 303
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5726
Practice Address - Country:US
Practice Address - Phone:586-997-3153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015522103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty