=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871668723
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW J WOLF LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 RED CEDAR ST AURORA COMMUNTIY COUNSELING EMPLOYEE SUPPORT & SERVICES
-----------------------------------------------------
City | MENOMONIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-235-4696
-----------------------------------------------------
Fax | 715-235-3941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20790 175TH STREET
-----------------------------------------------------
City | CORNELL
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-288-6926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6863 123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------