Healthcare Provider Details

I. General information

NPI: 1407970932
Provider Name (Legal Business Name): NINA ELAINE WENDT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S SANTA CLAUS LN UNIT 2
NORTH POLE AK
99705-7702
US

IV. Provider business mailing address

145 S SANTA CLAUS LN UNIT 2
NORTH POLE AK
99705-7702
US

V. Phone/Fax

Practice location:
  • Phone: 907-488-8848
  • Fax: 907-488-0695
Mailing address:
  • Phone: 907-488-8848
  • Fax: 907-488-0695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number311
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number610
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: