Provider Demographics
NPI:1922387190
Name:WOLF, PHYLLIS J (LPCS)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:J
Last Name:WOLF
Suffix:
Gender:F
Credentials:LPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:1202 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4612
Practice Address - Country:US
Practice Address - Phone:540-983-4053
Practice Address - Fax:540-981-9467
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18419101YP2500X
VA0701011243101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional