Healthcare Provider Details

I. General information

NPI: 1043950371
Provider Name (Legal Business Name): HEATHER WOLF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 OAK ST
LAS CRUCES NM
88005-3769
US

IV. Provider business mailing address

8176 CONSTITUTION RD
LAS CRUCES NM
88007-8983
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-2288
  • Fax:
Mailing address:
  • Phone: 262-364-7370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2022-0024
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: