Healthcare Provider Details

I. General information

NPI: 1427415736
Provider Name (Legal Business Name): MARK RONALD WENDT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W US HIGHWAY 2
WAKEFIELD MI
49968-9515
US

IV. Provider business mailing address

103 W US HIGHWAY 2
WAKEFIELD MI
49968-9515
US

V. Phone/Fax

Practice location:
  • Phone: 715-862-0419
  • Fax:
Mailing address:
  • Phone: 906-229-6120
  • Fax: 906-229-6191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401004423
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: