MEDICARE: HEATHER WALES WOLFE LCMFT

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	106H00000X	Marriage & Family Therapist	LCM669	MD

General Provider Information

NPI Number	:	1366930471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER WALES WOLFE LCMFT

Provider Business Mailing Address
First Line	:	22006 PHILIP DR
Second Line	:
City	:	LEONARDTOWN
State	:	MD
Zip	:	20650-2242
Country	:	US
Telephone Number	:	301-904-5580
Fax Number	:

Provider Business Practice Location Address
First Line	:	25484 POINT LOOKOUT RD STE 303C
Second Line	:
City	:	LEONARDTOWN
State	:	MD
Zip	:	20650-3843
Country	:	US
Telephone Number	:	301-475-9660
Fax Number	:

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

Provider Enumeration Date	:	04/24/2018
Last Update Date	:	04/24/2018

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