Provider Demographics
NPI:1073705299
Name:WOOD, RANDALL SCOTT (LMHC)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:SCOTT
Last Name:WOOD
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N 4TH ST
Mailing Address - Street 2:SUITE 506
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47901-1371
Mailing Address - Country:US
Mailing Address - Phone:765-409-6168
Mailing Address - Fax:
Practice Address - Street 1:133 N 4TH ST
Practice Address - Street 2:SUITE 506
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901-1371
Practice Address - Country:US
Practice Address - Phone:765-409-6168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-11
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001642A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health