Provider Demographics
NPI:1346232998
Name:WENTWORTH, LAWRENCE T (PHD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:T
Last Name:WENTWORTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11111 HALL RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-5711
Mailing Address - Country:US
Mailing Address - Phone:586-997-3153
Mailing Address - Fax:586-997-4956
Practice Address - Street 1:11111 HALL RD
Practice Address - Street 2:SUITE 303
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5711
Practice Address - Country:US
Practice Address - Phone:586-997-3153
Practice Address - Fax:586-997-4956
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007769103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P03030Medicare PIN
MIS08282Medicare UPIN