Provider Demographics
NPI:1093349292
Name:WOLFER, KALLEN ANN
Entity Type:Individual
Prefix:
First Name:KALLEN
Middle Name:ANN
Last Name:WOLFER
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 1:706 ARCH ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-3726
Mailing Address - Country:US
Mailing Address - Phone:616-644-5634
Mailing Address - Fax:
Practice Address - Street 1:100 N STAEBLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9755
Practice Address - Country:US
Practice Address - Phone:734-252-6522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820799715106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician