Provider Demographics
NPI:1245876556
Name:WOLF, COURTNEY LEE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEE
Last Name:WOLF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S BARSTOW ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3642
Mailing Address - Country:US
Mailing Address - Phone:715-461-0391
Mailing Address - Fax:715-838-8423
Practice Address - Street 1:120 S BARSTOW ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3642
Practice Address - Country:US
Practice Address - Phone:715-461-0391
Practice Address - Fax:715-838-8423
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator