Provider Demographics
NPI:1235254897
Name:WOLFE, MARY P (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:P
Last Name:WOLFE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4885 RAYBURN RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-3449
Mailing Address - Country:US
Mailing Address - Phone:321-271-1825
Mailing Address - Fax:
Practice Address - Street 1:1070 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1653
Practice Address - Country:US
Practice Address - Phone:321-729-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA39646225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty