Basic Information
| Provider Information | |||||||||
| NPI: | 1336707785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLFF | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 WILKES DR | ||||||||
| Address2: | STE 17 | ||||||||
| City: | GREEN RIVER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829354854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078751788 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1319 BEASER AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156823468 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2019 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 14695-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.