Provider Demographics
NPI:1649671645
Name:WOLF, AMY ROSE (LAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ROSE
Last Name:WOLF
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 W MADISON ST APT 3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2621
Mailing Address - Country:US
Mailing Address - Phone:312-757-1882
Mailing Address - Fax:
Practice Address - Street 1:70 E LAKE ST
Practice Address - Street 2:SUITE 630
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5959
Practice Address - Country:US
Practice Address - Phone:312-757-1882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001226171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist