Provider Demographics
NPI:1588713705
Name:WOLF, DENNIS KEITH (LCSW)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:KEITH
Last Name:WOLF
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19090 STILL POINT TRAIL
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045
Mailing Address - Country:US
Mailing Address - Phone:262-786-0912
Mailing Address - Fax:
Practice Address - Street 1:12065 W JANESVILLE ROAD
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130
Practice Address - Country:US
Practice Address - Phone:414-425-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2698123LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2698123OtherSTATE OF WIS DEPT OF REGU
WI39534600Medicaid