MEDICARE: THERESE L WOLF BA, ACA, BC-HIS

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	237700000X	Hearing Instrument Specialist	3501001328	MI

General Provider Information

NPI Number	:	1306849997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESE L WOLF BA, ACA, BC-HIS

Provider Business Mailing Address
First Line	:	2263 ANCIENT DR SW
Second Line	:
City	:	WYOMING
State	:	MI
Zip	:	49519-4849
Country	:	US
Telephone Number	:	616-538-9563
Fax Number	:

Provider Business Practice Location Address
First Line	:	734 ALGER ST SE
Second Line	:	STE 200
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3593
Country	:	US
Telephone Number	:	616-988-2158
Fax Number	:

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	07/08/2007

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