Provider Demographics
NPI:1346398922
Name:WOLFE, TINA LOU (PSYD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LOU
Last Name:WOLFE
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 1:31115 HIGHWAY 94
Mailing Address - Street 2:
Mailing Address - City:CAMPO
Mailing Address - State:CA
Mailing Address - Zip Code:91906-3133
Mailing Address - Country:US
Mailing Address - Phone:619-445-6200
Mailing Address - Fax:
Practice Address - Street 1:4690 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4403
Practice Address - Country:US
Practice Address - Phone:619-445-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28694103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical