Healthcare Provider Details

I. General information

NPI: 1629909684
Provider Name (Legal Business Name): CODY OWEN WOLF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10781 E CHERRY BEND RD
TRAVERSE CITY MI
49684-5249
US

IV. Provider business mailing address

10781 E CHERRY BEND RD
TRAVERSE CITY MI
49684-5249
US

V. Phone/Fax

Practice location:
  • Phone: 800-645-4737
  • Fax: 231-525-3170
Mailing address:
  • Phone: 800-645-4737
  • Fax: 231-525-3170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberW900001923141
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: