Provider Demographics
NPI:1891326989
Name:WOLFE, CHRISTY AMANDA (SUDPT)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:AMANDA
Last Name:WOLFE
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-6344
Mailing Address - Country:US
Mailing Address - Phone:509-571-1455
Mailing Address - Fax:
Practice Address - Street 1:613 SUPERIOR LN
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1623
Practice Address - Country:US
Practice Address - Phone:509-853-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61021991101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0755984Medicaid