Provider Demographics
NPI:1932616992
Name:WOLF, ANNA (RBT-17-40163)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:RBT-17-40163
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17920 DETROIT AVE APT 407
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3439
Mailing Address - Country:US
Mailing Address - Phone:216-513-2064
Mailing Address - Fax:
Practice Address - Street 1:24865 DETROIT RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2512
Practice Address - Country:US
Practice Address - Phone:440-250-8800
Practice Address - Fax:440-641-1170
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-17-40163106S00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician