Provider Demographics
NPI:1447562665
Name:WOLFE, TYRA JEAN (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:TYRA
Middle Name:JEAN
Last Name:WOLFE
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 N TEE TIME
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1628
Mailing Address - Country:US
Mailing Address - Phone:316-729-9756
Mailing Address - Fax:
Practice Address - Street 1:2830 N TEE TIME
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1628
Practice Address - Country:US
Practice Address - Phone:316-729-9756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00089224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant