Provider Demographics
NPI:1659978575
Name:WOOD, BERNADETTE ANTOINETTE
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:ANTOINETTE
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2944 KELLY ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-3459
Mailing Address - Country:US
Mailing Address - Phone:650-483-5949
Mailing Address - Fax:
Practice Address - Street 1:2944 KELLY ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-3459
Practice Address - Country:US
Practice Address - Phone:650-483-5949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-04
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA719001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANONEMedicaid