Provider Demographics
NPI:1205299781
Name:WOLFE, MYKEL (LCSW)
Entity type:Individual
Prefix:
First Name:MYKEL
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 W WALNUT ST
Mailing Address - Street 2:APT. D
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-2744
Mailing Address - Country:US
Mailing Address - Phone:618-841-4898
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:314-346-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0183831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical