Provider Demographics
NPI:1164465084
Name:WOOD, KELLE S (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:S
Last Name:WOOD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 PINE GROVE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-357-9318
Mailing Address - Fax:810-479-9684
Practice Address - Street 1:1423 PINE GROVE AVENUE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-357-9318
Practice Address - Fax:810-479-9684
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97240035Medicare ID - Type Unspecified