Provider Demographics
NPI:1639637689
Name:WOLTERSTORFF, TREVOR MARK
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:MARK
Last Name:WOLTERSTORFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:
Practice Address - Street 1:7511 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5997
Practice Address - Country:US
Practice Address - Phone:605-312-8700
Practice Address - Fax:757-446-8401
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD642103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist