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General NPI Number Information
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NPI Number | 1356735468
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Entity Type | Organization
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Legal Business Name | WENTWORTH AND ASSOCIATES, P.C.
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Dates
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Enumeration Date | 03/26/2015
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Last Update Date | 03/26/2015
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Provider Practice Location Address
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Address Line | 11111 HALL RD STE 303
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City | UTICA
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State | MI
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Zip | 48317-5726
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Country | US
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Telephone | 586-997-3153
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Fax |
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Provider Business Mailing Address
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Address Line | 28871 ALINE DR
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City | WARREN
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State | MI
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Zip | 48093-2690
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Country | US
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Telephone | 586-307-2137
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | LAWRENCE WENTWORTH
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Credential |
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Telephone | 586-997-3153
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301015522
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License Number State | MI
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