Provider Demographics
NPI:1184795080
Name:WOLFE, MARK STEPHEN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:WOLFE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4574
Mailing Address - Country:US
Mailing Address - Phone:770-949-1395
Mailing Address - Fax:
Practice Address - Street 1:110 EVANS MILL DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-1622
Practice Address - Country:US
Practice Address - Phone:770-445-6358
Practice Address - Fax:770-445-7262
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA888106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist