Provider Demographics
NPI:1205965670
Name:WOLVERTON, DANIEL TOD (PHD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:TOD
Last Name:WOLVERTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 GLENRIDGE PARK PL
Mailing Address - Street 2:STE 3
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3453
Mailing Address - Country:US
Mailing Address - Phone:502-893-8822
Mailing Address - Fax:
Practice Address - Street 1:6520 GLENRIDGE PARK PL
Practice Address - Street 2:STE 3
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-3453
Practice Address - Country:US
Practice Address - Phone:502-893-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0942103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP300041276OtherMEDICARE PTAN