Provider Demographics
NPI:1588320519
Name:WOLF, TATIANA M (MA72051)
Entity type:Individual
Prefix:MISS
First Name:TATIANA
Middle Name:M
Last Name:WOLF
Suffix:
Gender:F
Credentials:MA72051
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 MIDSUMMER AVE
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-1430
Mailing Address - Country:US
Mailing Address - Phone:407-793-8194
Mailing Address - Fax:
Practice Address - Street 1:1772 MIDSUMMER AVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-1430
Practice Address - Country:US
Practice Address - Phone:407-793-8194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA72051225700000X
MA72051225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist