Provider Demographics
NPI:1124010137
Name:WOLF, PETER C (MSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:C
Last Name:WOLF
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17146 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-3022
Mailing Address - Country:US
Mailing Address - Phone:313-415-0479
Mailing Address - Fax:
Practice Address - Street 1:31000 TELEGRAPH RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4360
Practice Address - Country:US
Practice Address - Phone:248-553-8550
Practice Address - Fax:734-454-3570
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010772071041C0700X
MA1103061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN65400018OtherMEDICARE PTAN(S)