Healthcare Provider Details

I. General information

NPI: 1972582757
Provider Name (Legal Business Name): MARTHA M. WOLF L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

773 W LINCOLN BLVD
FREEPORT IL
61032-4977
US

IV. Provider business mailing address

773 W LINCOLN BLVD
FREEPORT IL
61032-4977
US

V. Phone/Fax

Practice location:
  • Phone: 815-232-9050
  • Fax: 715-233-5995
Mailing address:
  • Phone: 815-232-9050
  • Fax: 715-233-5995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: