Provider Demographics
NPI:1073020913
Name:WOLFE, GAVIN PAYNE
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:PAYNE
Last Name:WOLFE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103B LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-3142
Mailing Address - Country:US
Mailing Address - Phone:850-362-6824
Mailing Address - Fax:850-362-6826
Practice Address - Street 1:103B LEWIS ST
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-3142
Practice Address - Country:US
Practice Address - Phone:850-362-6824
Practice Address - Fax:850-362-6826
Is Sole Proprietor?:No
Enumeration Date:2017-12-31
Last Update Date:2017-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician