Provider Demographics
NPI:1104052554
Name:WENDORF, ANTHONY DONALD (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:DONALD
Last Name:WENDORF
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038-9454
Mailing Address - Country:US
Mailing Address - Phone:262-719-0676
Mailing Address - Fax:
Practice Address - Street 1:840 LAKE AVENUE, SUITE 101
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1550
Practice Address - Country:US
Practice Address - Phone:262-634-8688
Practice Address - Fax:262-634-7547
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5977-27103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical