Provider Demographics
NPI:1558744854
Name:WOOD, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:1138 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ODESSA
Mailing Address - State:MI
Mailing Address - Zip Code:48849-1059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1138 6TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-1059
Practice Address - Country:US
Practice Address - Phone:517-388-2869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-04
Last Update Date:2015-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator