Healthcare Provider Details

I. General information

NPI: 1679106934
Provider Name (Legal Business Name): NICHOLE UILANI WOLF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 N DUTTON AVE # 95401
SANTA ROSA CA
95401-4609
US

IV. Provider business mailing address

609 JEFFERSON ST
FAIRFIELD CA
94533-6293
US

V. Phone/Fax

Practice location:
  • Phone: 707-888-2927
  • Fax:
Mailing address:
  • Phone: 707-718-4872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17620
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: