Provider Demographics
NPI:1891888087
Name:WOLF, SUSAN M (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:WOLF
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:NORWAISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:201 SHELDON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4513
Mailing Address - Country:US
Mailing Address - Phone:616-459-0255
Mailing Address - Fax:616-242-6057
Practice Address - Street 1:201 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4513
Practice Address - Country:US
Practice Address - Phone:616-459-0255
Practice Address - Fax:616-252-6057
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801061332104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI800D162220OtherBC/BS
MIS44147Medicare UPIN
MID16222105Medicare ID - Type UnspecifiedMECIARE