Healthcare Provider Details

I. General information

NPI: 1417618240
Provider Name (Legal Business Name): TRISHA ANNE WENTWORTH MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 12/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 GREEN BAY RD # 2
EVANSTON IL
60201-3026
US

IV. Provider business mailing address

2130 GREEN BAY RD # 2
EVANSTON IL
60201-3026
US

V. Phone/Fax

Practice location:
  • Phone: 847-425-9708
  • Fax:
Mailing address:
  • Phone: 847-425-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number16573
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: