Provider Demographics
NPI:1477581411
Name:WOLF, SUSAN KAY (LMHC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAY
Last Name:WOLF
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1526
Mailing Address - Country:US
Mailing Address - Phone:574-722-5151
Mailing Address - Fax:574-739-1414
Practice Address - Street 1:655 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2662
Practice Address - Country:US
Practice Address - Phone:765-472-1931
Practice Address - Fax:765-472-1945
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001516A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN512101OtherVALUE OPTIONS