Healthcare Provider Details

I. General information

NPI: 1700713070
Provider Name (Legal Business Name): THERESA LOUISE WOLGAST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 W 63RD ST
DAVENPORT IA
52806-1647
US

IV. Provider business mailing address

2711 W 63RD ST
DAVENPORT IA
52806-1647
US

V. Phone/Fax

Practice location:
  • Phone: 563-388-1039
  • Fax:
Mailing address:
  • Phone: 563-388-1039
  • Fax: 563-388-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: