Provider Demographics
NPI:1366509309
Name:WOLF, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5008
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47805-0008
Mailing Address - Country:US
Mailing Address - Phone:410-705-0664
Mailing Address - Fax:443-636-6573
Practice Address - Street 1:9 NEWBURG AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5157
Practice Address - Country:US
Practice Address - Phone:410-705-0664
Practice Address - Fax:443-636-6573
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3253101YM0800X
IN39004330A101YM0800X
MD4798101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health