Provider Demographics
NPI:1952502247
Name:WOOD, CONNIE MARIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARIE
Last Name:WOOD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 GARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-5730
Mailing Address - Country:US
Mailing Address - Phone:248-519-1212
Mailing Address - Fax:
Practice Address - Street 1:650 E BIG BEAVER RD
Practice Address - Street 2:SUITE A
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1432
Practice Address - Country:US
Practice Address - Phone:248-852-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011249103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical