Provider Demographics
NPI:1437135852
Name:WOLFF, MARTIN E (EDD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:E
Last Name:WOLFF
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N LONGWOOD ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4266
Mailing Address - Country:US
Mailing Address - Phone:815-962-6100
Mailing Address - Fax:815-962-6107
Practice Address - Street 1:631 N LONGWOOD ST
Practice Address - Street 2:SUITE 203
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4266
Practice Address - Country:US
Practice Address - Phone:815-962-6100
Practice Address - Fax:815-962-6107
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL686540Medicare ID - Type Unspecified
ILR17654Medicare UPIN