=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750192753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MCKENNA R WOLF
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2025
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34899 ROBERTS RD
-----------------------------------------------------
City | EASTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44095-2159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-429-5137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34899 ROBERTS RD
-----------------------------------------------------
City | EASTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44095-2159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-429-5137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CDCA.190918
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------