Provider Demographics
NPI:1790234292
Name:WOLCOTT, MAXWELL
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:WOLCOTT
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 1:2439 N MOZART ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2613
Mailing Address - Country:US
Mailing Address - Phone:301-717-9173
Mailing Address - Fax:
Practice Address - Street 1:1800 RAVINIA PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3761
Practice Address - Country:US
Practice Address - Phone:301-717-9173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-25
Last Update Date:2016-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.102023104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker