Provider Demographics
NPI:1316318413
Name:WOLF, KENNETH (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 BLOOMFIELD GLENS RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2513
Mailing Address - Country:US
Mailing Address - Phone:248-217-1677
Mailing Address - Fax:248-626-3759
Practice Address - Street 1:6330 BLOOMFIELD GLENS RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2513
Practice Address - Country:US
Practice Address - Phone:248-217-1677
Practice Address - Fax:248-626-3759
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002014103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical