1356368195 NPI number — WOLFE BEHAVIORAL HEALTH P.C.

Table of content: (NPI 1356368195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356368195 NPI number — WOLFE BEHAVIORAL HEALTH P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOLFE BEHAVIORAL HEALTH P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356368195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
683 JULI DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LENOX
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60451-1269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-462-3827
Provider Business Mailing Address Fax Number:
815-462-3837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
339 ALANA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451-1766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-462-3827
Provider Business Practice Location Address Fax Number:
815-462-3837
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOLFE
Authorized Official First Name:
DORA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
LICENSED CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
815-462-3827

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0009932429 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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