Provider Demographics
NPI:1538829908
Name:WOLF, HEATHER MICHELLE (PHD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MICHELLE
Last Name:WOLF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13371 LEHMANN CT
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4553
Mailing Address - Country:US
Mailing Address - Phone:228-265-2888
Mailing Address - Fax:
Practice Address - Street 1:13371 LEHMANN CT
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4553
Practice Address - Country:US
Practice Address - Phone:228-265-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS224622103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool