Provider Demographics
NPI:1194383489
Name:WOLF, MADELINE JILL (PSYD)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:JILL
Last Name:WOLF
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 PANDORA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6113
Mailing Address - Country:US
Mailing Address - Phone:310-842-7275
Mailing Address - Fax:
Practice Address - Street 1:300 S BEVERLY DR STE 205
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-4805
Practice Address - Country:US
Practice Address - Phone:310-842-7275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29761106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist