Provider Demographics
NPI:1184168031
Name:WENNER, TERA (BCBA)
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:WENNER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 MARVIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BELOIT
Mailing Address - State:IL
Mailing Address - Zip Code:61080-2247
Mailing Address - Country:US
Mailing Address - Phone:815-871-9222
Mailing Address - Fax:
Practice Address - Street 1:810 MARVIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BELOIT
Practice Address - State:IL
Practice Address - Zip Code:61080-2247
Practice Address - Country:US
Practice Address - Phone:815-871-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-10-7016103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst