Basic Information
| Provider Information | |||||||||
| NPI: | 1124524400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | GRACE | ||||||||
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| Credential: | MS, CRC, QP, LPCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285014933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102987167 | ||||||||
| FaxNumber: | 2526860021 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285466333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103784809 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2018 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A12562 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.