Basic Information
| Provider Information | |||||||||
| NPI: | 1346638889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENTWORTH | ||||||||
| FirstName: | SHARLETTA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC-MHSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 TECH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379122747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656379711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2455 SUTHERLAND AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655445000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2015 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 4064 | TN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | Q031260 | 05 | TN | MEDICAID |