Healthcare Provider Details

I. General information

NPI: 1821823659
Provider Name (Legal Business Name): MARISSA WOLF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE # C2
CERES CA
95307-4562
US

IV. Provider business mailing address

1904 RICHLAND AVE # C2
CERES CA
95307-4562
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4420
  • Fax: 209-558-4873
Mailing address:
  • Phone: 209-380-3539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-EASDQJ
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: