Healthcare Provider Details

I. General information

NPI: 1245876556
Provider Name (Legal Business Name): COURTNEY LEE WOLF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S BARSTOW ST
EAU CLAIRE WI
54701-3642
US

IV. Provider business mailing address

120 S BARSTOW ST
EAU CLAIRE WI
54701-3642
US

V. Phone/Fax

Practice location:
  • Phone: 715-461-0391
  • Fax: 715-838-8423
Mailing address:
  • Phone: 715-461-0391
  • Fax: 715-838-8423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number171M00000X
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: