Provider Demographics
NPI:1417420290
Name:WOLTER, WESLEY (MS,MA)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:WOLTER
Suffix:
Gender:M
Credentials:MS,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 BLOOD BROOK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLEE
Mailing Address - State:VT
Mailing Address - Zip Code:05045-9847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1461 BLOOD BROOK RD
Practice Address - Street 2:
Practice Address - City:FAIRLEE
Practice Address - State:VT
Practice Address - Zip Code:05045-9847
Practice Address - Country:US
Practice Address - Phone:802-299-1467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT81-2304276Medicaid