MEDICARE: MS. ALISA WOLF LCSW

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	1041C0700X	Clinical Social Worker	149008732	IL

General Provider Information

NPI Number	:	1932299138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALISA WOLF LCSW

Provider Business Mailing Address
First Line	:	325 IL ROUTE 2
Second Line	:
City	:	DIXON
State	:	IL
Zip	:	61021-9118
Country	:	US
Telephone Number	:	815-284-6611
Fax Number	:	815-284-6598

Provider Business Practice Location Address
First Line	:	325 IL ROUTE 2
Second Line	:
City	:	DIXON
State	:	IL
Zip	:	61021-9118
Country	:	US
Telephone Number	:	815-284-6611
Fax Number	:	815-284-6598

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	09/10/2010

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