Provider Demographics
NPI:1578528386
Name:WOOD, SALLY MEDORA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:MEDORA
Last Name:WOOD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-4553
Mailing Address - Country:US
Mailing Address - Phone:530-756-8754
Mailing Address - Fax:530-297-0766
Practice Address - Street 1:604 3RD ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4553
Practice Address - Country:US
Practice Address - Phone:530-756-8754
Practice Address - Fax:530-297-0766
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 10277103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7290-01OtherPACIFICARE
CA61-73217OtherUNITED HEALTHCARE SERVICE
CA680307290T4B2AUOtherHUMAN AFFAIRS INTERNATION
CA0001010300OtherMANAGED HEALTH NETWORK
CAA792509OtherVALUE OPTIONS
CAOPL102770OtherBLUE SHIELD OF CALIFORNIA
CAA792509OtherVALUE OPTIONS