Provider Demographics
NPI:1619205333
Name:WOLF, ELISSA MARY (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:MARY
Last Name:WOLF
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:MARY
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:421 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053-9764
Mailing Address - Country:US
Mailing Address - Phone:413-584-4040
Mailing Address - Fax:
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-584-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2731133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered