MEDICARE: KELSEY MARIE DOUGHERTY WOLF AUD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	147.001840	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	147.001840	OTHER	IL	ILLINOIS STATE LICENSE

General Provider Information

NPI Number	:	1174297659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY MARIE DOUGHERTY WOLF AUD

Provider Business Mailing Address
First Line	:	3340 OAK PARK AVE STE 204
Second Line	:
City	:	BERWYN
State	:	IL
Zip	:	60402-4591
Country	:	US
Telephone Number	:	708-749-3070
Fax Number	:	707-749-3410

Provider Business Practice Location Address
First Line	:	3340 OAK PARK AVE STE 204
Second Line	:
City	:	BERWYN
State	:	IL
Zip	:	60402-4591
Country	:	US
Telephone Number	:	708-749-3070
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2021
Last Update Date	:	03/10/2026

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