Provider Demographics
NPI:1780393744
Name:WOLF, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E 63RD ST FL 4
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64110-3303
Mailing Address - Country:US
Mailing Address - Phone:816-226-8619
Mailing Address - Fax:
Practice Address - Street 1:601 E 63RD ST FL 4
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3303
Practice Address - Country:US
Practice Address - Phone:816-226-8619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022029926101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health