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NPI Code Detail

MEDICARE: CLARISSA WENTWORTH

MEDICARE: CLARISSA WENTWORTH
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
11041C0700XClinical Social WorkerI1000187OH

General Provider Information

NPI Number : 1326352667
Entity Type Code : Individual
Provider Name (Legal Business Name) : CLARISSA WENTWORTH
Provider Business Mailing Address
First Line : 452 W MARKET ST
Second Line :
City : XENIA
State : OH
Zip : 45385-2815
Country : US
Telephone Number : 937-376-8700
Fax Number :
Provider Business Practice Location Address
First Line : 1321 RESEARCH PARK DR
Second Line :
City : BEAVERCREEK
State : OH
Zip : 45432-2851
Country : US
Telephone Number : 937-427-3837
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2010
Last Update Date : 07/28/2010

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