Provider Demographics
NPI:1245512078
Name:WOLF, BLAIR MATTHEW (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:MATTHEW
Last Name:WOLF
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:BLAIR
Other - Middle Name:CHERYL
Other - Last Name:MATTHEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:8117 CENTER RUN DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1945
Mailing Address - Country:US
Mailing Address - Phone:317-570-9205
Mailing Address - Fax:
Practice Address - Street 1:8117 CENTER RUN DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1945
Practice Address - Country:US
Practice Address - Phone:317-570-9205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005364A235Z00000X
IL146010343235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist