MEDICARE: MS. SHIRLEY ANN WOOLFOLK LICDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	161470	OH

General Provider Information

NPI Number	:	1194249680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHIRLEY ANN WOOLFOLK LICDC

Provider Business Mailing Address
First Line	:	3540 CROTON AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-3212
Country	:	US
Telephone Number	:	216-202-1017
Fax Number	:

Provider Business Practice Location Address
First Line	:	3577 E 144TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-4808
Country	:	US
Telephone Number	:	216-338-5788
Fax Number	:	216-338-5788

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

Provider Enumeration Date	:	07/27/2017
Last Update Date	:	07/27/2017

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