=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497924914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANIS L WOLF LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2008
-----------------------------------------------------
Last Update Date | 04/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 LAKE LAND BLVD
-----------------------------------------------------
City | MATTOON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61938-5283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-258-3370
-----------------------------------------------------
Fax | 217-258-3379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 LAKELAND BLVD
-----------------------------------------------------
City | MATTOON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61938-4610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-238-3370
-----------------------------------------------------
Fax | 217-258-3379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149007080
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------