Provider Demographics
NPI:1609007954
Name:WOLF, TERESE ANGELA (MS, LPC)
Entity Type:Individual
Prefix:MS
First Name:TERESE
Middle Name:ANGELA
Last Name:WOLF
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:MS
Other - First Name:TERESE
Other - Middle Name:ANGELA
Other - Last Name:WALZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-0302
Mailing Address - Country:US
Mailing Address - Phone:303-517-7396
Mailing Address - Fax:300-500-7018
Practice Address - Street 1:77 ERIE VILLAGE SQ
Practice Address - Street 2:SUITE 160
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516-6992
Practice Address - Country:US
Practice Address - Phone:303-517-7396
Practice Address - Fax:303-500-7018
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2514101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
26-3913892OtherIRS TIN