Provider Demographics
NPI:1114455516
Name:WOLF CRAIG, KELLY SUZANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:SUZANNE
Last Name:WOLF CRAIG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SUZANNE
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:100 CENTURY DR
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-1244
Practice Address - Country:US
Practice Address - Phone:508-762-5400
Practice Address - Fax:508-762-5410
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3525103TC0700X
MA10605103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical