Provider Demographics
NPI:1194215053
Name:WOLFE, DEDRICK
Entity Type:Individual
Prefix:
First Name:DEDRICK
Middle Name:
Last Name:WOLFE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 HIGHWAY 74 APT 407
Mailing Address - Street 2:
Mailing Address - City:SAINT GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776-4566
Mailing Address - Country:US
Mailing Address - Phone:225-620-1301
Mailing Address - Fax:
Practice Address - Street 1:6610 HIGHWAY 74 APT 407
Practice Address - Street 2:
Practice Address - City:SAINT GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776-4566
Practice Address - Country:US
Practice Address - Phone:225-620-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator