Provider Demographics
NPI:1497933543
Name:WOOD, NICOLE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-6024
Mailing Address - Country:US
Mailing Address - Phone:618-443-8023
Mailing Address - Fax:
Practice Address - Street 1:10820 SUNSET OFFICE DR
Practice Address - Street 2:SUITE 108
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1016
Practice Address - Country:US
Practice Address - Phone:314-956-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070347511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494057805Medicaid