MEDICARE: SANDRA WENCLASKY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	11917	TX

General Provider Information

NPI Number	:	1194284885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA WENCLASKY

Provider Business Mailing Address
First Line	:	3604 WINIFRED DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2127
Country	:	US
Telephone Number	:	817-296-1388
Fax Number	:

Provider Business Practice Location Address
First Line	:	3604 WINIFRED DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2127
Country	:	US
Telephone Number	:	817-296-1388
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2019
Last Update Date	:	03/13/2019

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Directions to “ SANDRA WENCLASKY ” Practice Location

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