Provider Demographics
NPI:1528164498
Name:WOLFE, SUSAN E (LMST)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:E
Last Name:WOLFE
Suffix:
Gender:F
Credentials:LMST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 LEE RD
Mailing Address - Street 2:STE 214
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2115
Mailing Address - Country:US
Mailing Address - Phone:407-252-8235
Mailing Address - Fax:
Practice Address - Street 1:1850 LEE RD
Practice Address - Street 2:STE 214
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2115
Practice Address - Country:US
Practice Address - Phone:407-252-8235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 103T00000X
FLMT1453103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMT1453Medicare UPIN