Healthcare Provider Details

I. General information

NPI: 1043015837
Provider Name (Legal Business Name): WOLVERINE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 WENDELL AVE STE 100
PITTSFIELD MA
01201-7066
US

IV. Provider business mailing address

82 WENDELL AVE STE 100
PITTSFIELD MA
01201-7066
US

V. Phone/Fax

Practice location:
  • Phone: 617-517-6340
  • Fax: 423-301-6604
Mailing address:
  • Phone: 617-517-6340
  • Fax: 423-301-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ETHAN SLABAUGH
Title or Position: NURSE PRACTITIONER
Credential: DNP, FNP-BC, BSN, RN
Phone: 617-517-6340