Provider Demographics
NPI:1124524400
Name:WOLF, GRACE (MS, CRC, QP, LPCA)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:MS, CRC, QP, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-4933
Mailing Address - Country:US
Mailing Address - Phone:910-298-7167
Mailing Address - Fax:252-686-0021
Practice Address - Street 1:215 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6333
Practice Address - Country:US
Practice Address - Phone:910-378-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12562101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health