Provider Demographics
NPI:1760093967
Name:WOLFE, MARISSA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 W BRYN MAWR AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3524
Mailing Address - Country:US
Mailing Address - Phone:773-644-7787
Mailing Address - Fax:
Practice Address - Street 1:301 S VINE ST UNIT 10
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-7404
Practice Address - Country:US
Practice Address - Phone:224-298-7462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-22-60654103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst