Provider Demographics
NPI:1780942334
Name:WOLFE, MARION CORNELIUS JR (ASW70101)
Entity type:Individual
Prefix:MR
First Name:MARION
Middle Name:CORNELIUS
Last Name:WOLFE
Suffix:JR
Gender:M
Credentials:ASW70101
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6011 STACY AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-3945
Mailing Address - Country:US
Mailing Address - Phone:916-583-1035
Mailing Address - Fax:
Practice Address - Street 1:900 FULTON AVE STE 205
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4517
Practice Address - Country:US
Practice Address - Phone:916-484-3570
Practice Address - Fax:916-484-3577
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW70101104100000X
CA70101101Y00000X
CA03-109797101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03-109797OtherCAS AOD CERTIFICATION