Provider Demographics
NPI:1114079522
Name:WOLFORD, CHARLES WALTER (LSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WALTER
Last Name:WOLFORD
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686-2100
Mailing Address - Country:US
Mailing Address - Phone:814-684-4022
Mailing Address - Fax:814-889-7999
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4804
Practice Address - Country:US
Practice Address - Phone:814-889-2141
Practice Address - Fax:814-889-7999
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW004708E1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA17595OtherGEISINGER
PA138020OtherGADRIAN CIGNA BEHAVIORAL
PA273989OtherMAGELLAN
PA629812OtherHIGHMARK