Basic Information
| Provider Information | |||||||||
| NPI: | 1104467851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFF | ||||||||
| FirstName: | DETLEV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 W 6TH ST STE 11 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136074400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1111 W 6TH ST STE 11 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136074400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2019 | ||||||||
| LastUpdateDate: | 09/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 13586 | CA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 30310 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.