Provider Demographics
NPI:1548811904
Name:WACHOLZ, STANLEY KEITH (BS BIS)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:KEITH
Last Name:WACHOLZ
Suffix:
Gender:M
Credentials:BS BIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5723 E DODD RD
Mailing Address - Street 2:
Mailing Address - City:HAYDEN LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9376
Mailing Address - Country:US
Mailing Address - Phone:208-651-8985
Mailing Address - Fax:
Practice Address - Street 1:5723 E DODD RD
Practice Address - Street 2:
Practice Address - City:HAYDEN LAKE
Practice Address - State:ID
Practice Address - Zip Code:83835-9376
Practice Address - Country:US
Practice Address - Phone:208-651-8985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
ID106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst