Basic Information
| Provider Information | |||||||||
| NPI: | 1245413913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENTZ | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | JEANNE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 S BROADWAY | ||||||||
| Address2: | SUITE 18 | ||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018578500 | ||||||||
| FaxNumber: | 7018578555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1237 W DIVIDE AVE STE 5 | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585011208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013288745 | ||||||||
| FaxNumber: | 7018578555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2007 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 079317 | ND | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | 3929 | ND | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 054517 | 05 | ND | MEDICAID |