Provider Demographics
NPI:1609172402
Name:WOOD, MATT (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 WHITEWATER DR
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7851
Mailing Address - Country:US
Mailing Address - Phone:919-805-2098
Mailing Address - Fax:
Practice Address - Street 1:419 WHITEWATER DR
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7851
Practice Address - Country:US
Practice Address - Phone:919-805-2098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-10-7795103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst