Provider Demographics
NPI:1033102892
Name:WOLF, SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 GARDEN STATE DR
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-1915
Mailing Address - Country:US
Mailing Address - Phone:856-482-7023
Mailing Address - Fax:
Practice Address - Street 1:1101 N KINGS HWY
Practice Address - Street 2:SUITE 304
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1912
Practice Address - Country:US
Practice Address - Phone:856-482-7023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ03585103TC1900X
PAPS-006490-L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ133OtherPBH
NJ153300OtherMHN
NJ153300OtherMHN
NJ045480Medicare ID - Type Unspecified