Basic Information
| Provider Information | |||||||||
| NPI: | 1083764534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENTZ | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1603 MEDICAL DR STE A | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283525541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102767011 | ||||||||
| FaxNumber: | 9102767060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1603 MEDICAL DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283525540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102767011 | ||||||||
| FaxNumber: | 9102767060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5162 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6103157 | 05 | NC | MEDICAID | 141Y3 | 01 | NC | BCBS | OTHER | 186211 | 01 | NC | MEDCOST | OTHER |