Provider Demographics
NPI:1639682560
Name:WULF, MAAYAN (DSOM, LAC)
Entity type:Individual
Prefix:
First Name:MAAYAN
Middle Name:
Last Name:WULF
Suffix:
Gender:F
Credentials:DSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26197 TINY FARM LN
Mailing Address - Street 2:
Mailing Address - City:ARLEE
Mailing Address - State:MT
Mailing Address - Zip Code:59821-8500
Mailing Address - Country:US
Mailing Address - Phone:406-304-9904
Mailing Address - Fax:
Practice Address - Street 1:1805 BANCROFT ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5781
Practice Address - Country:US
Practice Address - Phone:406-304-9904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT59048171100000X
171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist