Provider Demographics
NPI:1992939219
Name:WENZEL, KATHRYN L (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:L
Last Name:WENZEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6821 MAIN ST SUITE C
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805
Mailing Address - Country:US
Mailing Address - Phone:208-267-9228
Mailing Address - Fax:
Practice Address - Street 1:6821 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-8552
Practice Address - Country:US
Practice Address - Phone:208-267-9228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID362431041C0700X
CO099245481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12018496OtherCAQH
CO09924548OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES
ID36243OtherBUREAU OF OCCUPATIONAL LICENSES