Provider Demographics
NPI:1003355090
Name:WOLF CREEK WELLNESS LLC
Entity Type:Organization
Organization Name:WOLF CREEK WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MAROON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-690-2337
Mailing Address - Street 1:680 HIGH ST STE A
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1690
Mailing Address - Country:US
Mailing Address - Phone:330-690-2337
Mailing Address - Fax:330-822-6955
Practice Address - Street 1:680 HIGH ST STE A
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1690
Practice Address - Country:US
Practice Address - Phone:306-902-3373
Practice Address - Fax:330-822-6955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE.0007875OtherLICENSE
OH0251028Medicaid