MEDICARE: MR. MARK ANTHONY DEWOLF MA, LPC, NCC

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	101YP2500X	Professional Counselor	LPC.0015925	CO

General Provider Information

NPI Number	:	1356791834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ANTHONY DEWOLF MA, LPC, NCC

Provider Business Mailing Address
First Line	:	8050 NIWOT RD APT 3
Second Line	:
City	:	NIWOT
State	:	CO
Zip	:	80503-8690
Country	:	US
Telephone Number	:	970-470-1240
Fax Number	:

Provider Business Practice Location Address
First Line	:	3333 IRIS AVE STE 210
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80301-1998
Country	:	US
Telephone Number	:	970-470-1240
Fax Number	:

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

Provider Enumeration Date	:	06/15/2016
Last Update Date	:	07/05/2023

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