Healthcare Provider Details

I. General information

NPI: 1538694211
Provider Name (Legal Business Name): ANDREA WOLFE-CLARK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA WOLFE

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DFAS JFLL IN 8899 EAST 56TH STREET
INDIANAPOLIS IN
46249-1200
US

IV. Provider business mailing address

3250 ZEMKE AVE
TAMPA FL
33621-5023
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-5972
  • Fax:
Mailing address:
  • Phone: 210-292-5972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810006382
License Number StateVA
# 2
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: