Provider Demographics
NPI:1750192753
Name:WOLF, MCKENNA R
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:R
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 1:34899 ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-2159
Mailing Address - Country:US
Mailing Address - Phone:630-429-5137
Mailing Address - Fax:
Practice Address - Street 1:34899 ROBERTS RD
Practice Address - Street 2:
Practice Address - City:EASTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-2159
Practice Address - Country:US
Practice Address - Phone:630-429-5137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.190918101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)