Provider Demographics
NPI:1891311197
Name:WOOD, CAROLYN ELAINE (LMT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ELAINE
Last Name:WOOD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3377
Mailing Address - Country:US
Mailing Address - Phone:321-567-4561
Mailing Address - Fax:321-567-4561
Practice Address - Street 1:113 S PARK AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3377
Practice Address - Country:US
Practice Address - Phone:321-567-4561
Practice Address - Fax:321-567-4561
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA91457225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist