Provider Demographics
NPI:1508110289
Name:WOOD, RAYMOND MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:MICHAEL
Last Name:WOOD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N. LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916
Mailing Address - Country:US
Mailing Address - Phone:920-887-8751
Mailing Address - Fax:920-887-3977
Practice Address - Street 1:108 N. LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-887-8751
Practice Address - Fax:920-887-3977
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1713-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist