Provider Demographics
NPI:1487606497
Name:WACK, DENNIS L (PHD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:L
Last Name:WACK
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 1:4045 WADSWORTH BLVD
Mailing Address - Street 2:# 308
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4642
Mailing Address - Country:US
Mailing Address - Phone:303-421-1896
Mailing Address - Fax:303-237-3589
Practice Address - Street 1:4045 WADSWORTH BLVD
Practice Address - Street 2:# 308
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4642
Practice Address - Country:US
Practice Address - Phone:303-421-1896
Practice Address - Fax:303-237-3589
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1083103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO537078Medicare ID - Type Unspecified
CO537098Medicare ID - Type Unspecified