Provider Demographics
NPI:1962699645
Name:WENGER, H DAVID (PHD)
Entity type:Individual
Prefix:
First Name:H
Middle Name:DAVID
Last Name:WENGER
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 1:1905 ABBOT RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1905 ABBOT RD
Practice Address - Street 2:SUITE 4
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8571
Practice Address - Country:US
Practice Address - Phone:517-351-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001472103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI062C34574OtherBCBSM