Healthcare Provider Details

I. General information

NPI: 1124010137
Provider Name (Legal Business Name): PETER C WOLF MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31000 TELEGRAPH RD SUITE 120
BINGHAM FARMS MI
48025-4360
US

IV. Provider business mailing address

17146 FAIRFIELD ST
DETROIT MI
48221-3022
US

V. Phone/Fax

Practice location:
  • Phone: 248-553-8550
  • Fax: 734-454-3570
Mailing address:
  • Phone: 313-415-0479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801077207
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110306
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: