Basic Information
| Provider Information | |||||||||
| NPI: | 1215273263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENK | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7325 SOM CENTER RD | ||||||||
| Address2: | |||||||||
| City: | SOLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441394905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402484185 | ||||||||
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| Practice Location | |||||||||
| Address1: | 919 2ND ST NE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447041132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304547917 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2012 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 103TC2200X | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.