Healthcare Provider Details

I. General information

NPI: 1285747592
Provider Name (Legal Business Name): L STANLEY WENCK EDD, HSPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 W JACKSON ST
MUNCIE IL
47304-4371
US

IV. Provider business mailing address

3111 W JACKSON ST
MUNCIE IL
47304-4371
US

V. Phone/Fax

Practice location:
  • Phone: 765-284-0879
  • Fax: 765-284-1480
Mailing address:
  • Phone: 765-284-0879
  • Fax: 765-284-1480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20090044A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: