Provider Demographics
NPI:1386761930
Name:WENTWORTH, CARLENE MCDEARIS (PHD)
Entity type:Individual
Prefix:DR
First Name:CARLENE
Middle Name:MCDEARIS
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 HAMMOND RD
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:SC
Mailing Address - Zip Code:29627-9452
Mailing Address - Country:US
Mailing Address - Phone:864-760-3150
Mailing Address - Fax:
Practice Address - Street 1:422 HAMMOND RD
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:SC
Practice Address - Zip Code:29627-9452
Practice Address - Country:US
Practice Address - Phone:864-760-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1989101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1386761930Medicaid