Provider Demographics
NPI:1447558499
Name:WENGER, SHAUNDA
Entity type:Individual
Prefix:
First Name:SHAUNDA
Middle Name:
Last Name:WENGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3788
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-3788
Mailing Address - Country:US
Mailing Address - Phone:406-262-3885
Mailing Address - Fax:
Practice Address - Street 1:1035 1ST AVE W STE 210
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5607
Practice Address - Country:US
Practice Address - Phone:406-607-4938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0182351101YP2500X
MTLCPC 1529101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional