Provider Demographics
NPI:1154308419
Name:WOLF, MARY K (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:WOLF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:TRENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:32 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-3941
Mailing Address - Country:US
Mailing Address - Phone:608-618-5560
Mailing Address - Fax:855-277-9589
Practice Address - Street 1:32 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3941
Practice Address - Country:US
Practice Address - Phone:608-618-5560
Practice Address - Fax:855-277-9589
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102871041C0700X
WI82601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100053097Medicaid
MN101622900Medicaid
MN800002491Medicare PIN
MN800011631Medicare ID - Type UnspecifiedRAILROAD