Provider Demographics
NPI:1508570342
Name:WOLFE, BAILEY
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10198 W GARVERDALE LN APT 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8044
Mailing Address - Country:US
Mailing Address - Phone:208-995-9627
Mailing Address - Fax:
Practice Address - Street 1:738 S BRIDGEWAY PL STE 150
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6953
Practice Address - Country:US
Practice Address - Phone:208-908-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician