Provider Demographics
NPI:1831214121
Name:WOLF, AMY D (LICSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:D
Last Name:WOLF
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 HARRY KEMP WAY
Mailing Address - Street 2:OUTER CAPE HEALTH SERVICES
Mailing Address - City:PROVINCETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02657
Mailing Address - Country:US
Mailing Address - Phone:508-487-9395
Mailing Address - Fax:508-487-3285
Practice Address - Street 1:49 HARRY KEMP WAY
Practice Address - Street 2:OUTER CAPE HEALTH SERVICES
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657
Practice Address - Country:US
Practice Address - Phone:508-487-9395
Practice Address - Fax:508-487-3285
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1108851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1895770Medicaid