Provider Demographics
NPI:1952769499
Name:WOLF, MEGAN A (LCSW)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:A
Last Name:WOLF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:2275 S EAGLE RD STE 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-514-2520
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID33563101YM0800X, 104100000X
IDLCSW-369041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1952769499Medicaid