Provider Demographics
NPI:1043950371
Name:WOLF, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WOLF
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 1:8176 CONSTITUTION RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-8983
Mailing Address - Country:US
Mailing Address - Phone:262-364-7370
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3769
Practice Address - Country:US
Practice Address - Phone:575-523-2288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0024101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty