=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265299440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA WOLF LCMHCA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2024
-----------------------------------------------------
Last Update Date | 03/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20605 N MAIN ST
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-8454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-788-9800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9735 AEGEAN CT
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-5919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-930-8559
-----------------------------------------------------
Fax | 980-788-9900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A19753
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------