Provider Demographics
NPI:1912436189
Name:WOLF, ALEXIS MARIE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MARIE
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 1:11810 TEDFORD ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-2130
Mailing Address - Country:US
Mailing Address - Phone:512-733-9704
Mailing Address - Fax:
Practice Address - Street 1:11810 TEDFORD ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-2130
Practice Address - Country:US
Practice Address - Phone:512-733-9704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60977139101YM0800X
101YP2500X
TX85462101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88-1484457Medicaid