Provider Demographics
NPI:1376914499
Name:WOLFE, MARY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:WOLFE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:REVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:2050 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2048
Practice Address - Country:US
Practice Address - Phone:219-662-3300
Practice Address - Fax:219-662-3301
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001978A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM100047140OtherMEDICARE GROUP NUMBER