Provider Demographics
NPI:1417508433
Name:WOLF, BENJAMIN (OTR/L)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21842 N 31ST DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-1685
Mailing Address - Country:US
Mailing Address - Phone:610-291-1580
Mailing Address - Fax:
Practice Address - Street 1:3660 W BETHANY HOME RD STE B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-1953
Practice Address - Country:US
Practice Address - Phone:602-626-8851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty