=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467789198
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE DEBORAH WOLF MED., BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2009
-----------------------------------------------------
Last Update Date | 11/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 FONTANA DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63146-3830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-961-8983
-----------------------------------------------------
Fax | 314-961-8983
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 LADEL CT
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-4321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-961-8983
-----------------------------------------------------
Fax | 314-961-8983
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-04-1597
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------