Provider Demographics
NPI:1013222595
Name:WOLF, MONA (COTA/L)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 S WHITE MOUNTAIN RD
Mailing Address - Street 2:APT. 123
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7309
Mailing Address - Country:US
Mailing Address - Phone:928-251-4851
Mailing Address - Fax:
Practice Address - Street 1:2401 E HUNT ST
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7920
Practice Address - Country:US
Practice Address - Phone:928-537-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4524224Z00000X
MN201562224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant