Healthcare Provider Details

I. General information

NPI: 1164697967
Provider Name (Legal Business Name): PAUL WEHNER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 S 6TH ST
SPRINGFIELD IL
62703-2406
US

IV. Provider business mailing address

1124 S 6TH ST
SPRINGFIELD IL
62703-2406
US

V. Phone/Fax

Practice location:
  • Phone: 217-523-3143
  • Fax: 217-523-7695
Mailing address:
  • Phone: 217-523-3143
  • Fax: 217-523-7695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008254
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: