Provider Demographics
NPI:1891095733
Name:WOLF, MITCHELL (LAC)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 WEST 21ST STREET
Mailing Address - Street 2:SUITE 904
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010
Mailing Address - Country:US
Mailing Address - Phone:917-608-7837
Mailing Address - Fax:
Practice Address - Street 1:19 W 21ST ST RM 904
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6851
Practice Address - Country:US
Practice Address - Phone:917-608-7837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000712171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist