Provider Demographics
NPI:1114492303
Name:WOLFRAM, CARLY (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:WOLFRAM
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 TALL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-4204
Mailing Address - Country:US
Mailing Address - Phone:815-236-5503
Mailing Address - Fax:
Practice Address - Street 1:1 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-1708
Practice Address - Country:US
Practice Address - Phone:815-236-5503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014654101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1114492303OtherINDIVIDUAL NPI