Provider Demographics
NPI:1679221469
Name:WOOD, LORENE MICHELLE (MA)
Entity Type:Individual
Prefix:MRS
First Name:LORENE
Middle Name:MICHELLE
Last Name:WOOD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24254 BRECKENRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4366
Mailing Address - Country:US
Mailing Address - Phone:909-860-8141
Mailing Address - Fax:
Practice Address - Street 1:24254 BRECKENRIDGE CT
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4366
Practice Address - Country:US
Practice Address - Phone:909-860-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43677106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist