Provider Demographics
NPI:1679209688
Name:WENDEL, MOIRA
Entity type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:WENDEL
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 1:1753 JACKSON AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4061
Mailing Address - Country:US
Mailing Address - Phone:630-863-1787
Mailing Address - Fax:
Practice Address - Street 1:10524 E GRAND RIVER AVE
Practice Address - Street 2:STE 100
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116
Practice Address - Country:US
Practice Address - Phone:810-225-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63620095491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical