Provider Demographics
NPI:1003145160
Name:WOOD, SHANTE NICHOLE LEE (MED)
Entity Type:Individual
Prefix:MRS
First Name:SHANTE
Middle Name:NICHOLE LEE
Last Name:WOOD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SPRUCE CT
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3628
Mailing Address - Country:US
Mailing Address - Phone:610-842-7524
Mailing Address - Fax:
Practice Address - Street 1:5 SPRUCE CT
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3628
Practice Address - Country:US
Practice Address - Phone:610-842-7524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health