Provider Demographics
NPI:1598131807
Name:WOOD, RUSSELL S (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:S
Last Name:WOOD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:RUSS
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:4971 E INTERSTATE 20 SERVICE RD N STE 100
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-3206
Mailing Address - Country:US
Mailing Address - Phone:817-694-8916
Mailing Address - Fax:682-224-5724
Practice Address - Street 1:4971 E INTERSTATE 20 SERVICE RD N STE 100
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087-3206
Practice Address - Country:US
Practice Address - Phone:817-694-8916
Practice Address - Fax:682-224-5724
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32761103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical