Basic Information
Provider Information | |||||||||
NPI: | 1457665929 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WENGER | ||||||||
FirstName: | KAITLIN | ||||||||
MiddleName: | T. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 219 WINGED FOOT DR | ||||||||
Address2: |   | ||||||||
City: | BLUE BELL | ||||||||
State: | PA | ||||||||
PostalCode: | 194223211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2673044442 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 523 PLYMOUTH RD | ||||||||
Address2: | #215 | ||||||||
City: | PLYMOUTH MEETING | ||||||||
State: | PA | ||||||||
PostalCode: | 194621656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109542400 | ||||||||
FaxNumber: | 6109543697 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2010 | ||||||||
LastUpdateDate: | 05/02/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CW016535 | PA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.