MEDICARE: WHITE WOLF MINISTRY

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1245878958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE WOLF MINISTRY

Provider Business Mailing Address
First Line	:	7959 VT ROUTE 125
Second Line	:
City	:	BRIDPORT
State	:	VT
Zip	:	05734-4401
Country	:	US
Telephone Number	:	973-476-3648
Fax Number	:

Provider Business Practice Location Address
First Line	:	7959 VT ROUTE 125
Second Line	:
City	:	BRIDPORT
State	:	VT
Zip	:	05734-4401
Country	:	US
Telephone Number	:	802-758-2222
Fax Number	:

Authorized Official
Title or Position	:	TRUSTEE
Name	:	RALPH FUCETOLA
Credential	:	JD
Telephone Number	:	973-300-4594

Provider Enumeration Date	:	12/12/2019
Last Update Date	:	12/12/2019

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Directions to “WHITE WOLF MINISTRY ” Practice Location

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