Provider Demographics
NPI:1831682020
Name:WENTWORTH, ANGELLICA MARIE
Entity type:Individual
Prefix:MRS
First Name:ANGELLICA
Middle Name:MARIE
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 WALTHER BLVD APT 2714
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8437
Mailing Address - Country:US
Mailing Address - Phone:404-285-0745
Mailing Address - Fax:
Practice Address - Street 1:4146 HIGHWAY 278 NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2494
Practice Address - Country:US
Practice Address - Phone:770-787-3788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist