Provider Demographics
NPI:1134160336
Name:WOOD, GWEN W (MA, PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:W
Last Name:WOOD
Suffix:
Gender:F
Credentials:MA, PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3717
Mailing Address - Country:US
Mailing Address - Phone:859-331-3292
Mailing Address - Fax:859-578-2864
Practice Address - Street 1:318 MONJOY STREET
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:KY
Practice Address - Zip Code:41040-1132
Practice Address - Country:US
Practice Address - Phone:859-654-6988
Practice Address - Fax:859-654-3763
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184607OtherMEDICARE GROUP NUMBER