Provider Demographics
NPI:1922833508
Name:WENTZ, KELLY (CADC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WENTZ
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 5TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1510
Mailing Address - Country:US
Mailing Address - Phone:712-253-7100
Mailing Address - Fax:
Practice Address - Street 1:505 5TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1510
Practice Address - Country:US
Practice Address - Phone:712-253-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24065101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)