Provider Demographics
NPI:1164653713
Name:WOOD, KENDRA OTIS (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:OTIS
Last Name:WOOD
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:MICHELLE
Other - Last Name:OTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8208 BROKEN ARROW DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-1201
Mailing Address - Country:US
Mailing Address - Phone:850-445-9096
Mailing Address - Fax:
Practice Address - Street 1:8208 BROKEN ARROW DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-1201
Practice Address - Country:US
Practice Address - Phone:850-445-9096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9945235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001435700Medicaid