Provider Demographics
NPI:1518594688
Name:WOOD, MARY GRACE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11580 PALO ALTO RD
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-3751
Mailing Address - Country:US
Mailing Address - Phone:703-472-0895
Mailing Address - Fax:
Practice Address - Street 1:11580 PALO ALTO RD
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657-3751
Practice Address - Country:US
Practice Address - Phone:703-472-0895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer