Provider Demographics
NPI:1598095697
Name:WOLF, HOLLY J (PHD)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:J
Last Name:WOLF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:HOLLY
Other - Middle Name:J
Other - Last Name:DANNEWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2808 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-746-8376
Mailing Address - Fax:701-746-9872
Practice Address - Street 1:2808 17TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-746-8376
Practice Address - Fax:701-746-9872
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND433103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15106Medicaid
NDN719569Medicare PIN