Provider Demographics
NPI:1629167978
Name:WOLF, BETH A (MSCCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:A
Last Name:WOLF
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3532 19TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6552
Mailing Address - Country:US
Mailing Address - Phone:701-293-3345
Mailing Address - Fax:
Practice Address - Street 1:3532 19TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6552
Practice Address - Country:US
Practice Address - Phone:701-293-3345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND514235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND23560OtherBLUE CROSS BLUE SHIELD ND
ND051424Medicaid