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General NPI Number Information
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NPI Number | 1043015837
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Entity Type | Organization
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Legal Business Name | WOLVERINE HEALTHCARE LLC
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Dates
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Enumeration Date | 02/15/2025
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Last Update Date | 02/19/2025
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Provider Practice Location Address
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Address Line | 82 WENDELL AVE STE 100
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City | PITTSFIELD
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State | MA
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Zip | 01201-7066
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Country | US
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Telephone | 617-517-6340
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Fax | 423-301-6604
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Provider Business Mailing Address
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Address Line | 82 WENDELL AVE STE 100
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City | PITTSFIELD
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State | MA
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Zip | 01201-7066
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Country | US
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Telephone | 617-517-6340
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Fax | 423-301-6604
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | ETHAN SLABAUGH
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Credential | DNP, FNP-BC, BSN, RN
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Telephone | 617-517-6340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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