Provider Demographics
NPI:1720515349
Name:WOLF, MITCHELL (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5329 MALCOLM ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-2310
Mailing Address - Country:US
Mailing Address - Phone:760-593-9945
Mailing Address - Fax:
Practice Address - Street 1:5329 MALCOLM ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-2310
Practice Address - Country:US
Practice Address - Phone:760-593-9945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-13
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17303225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist