Provider Demographics
NPI:1538370820
Name:WOLF, BENJAMIN J (LICSW)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:J
Last Name:WOLF
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11105 ZEBULON PIKE AVE
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-1151
Mailing Address - Country:US
Mailing Address - Phone:612-802-9398
Mailing Address - Fax:
Practice Address - Street 1:13750 CROSSTOWN DR NW
Practice Address - Street 2:SUITE L101
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-5853
Practice Address - Country:US
Practice Address - Phone:763-482-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN169651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical