Provider Demographics
NPI:1134770332
Name:WOOD, KENNETH (CRM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 FRUITVALE RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-9671
Mailing Address - Country:US
Mailing Address - Phone:541-270-8767
Mailing Address - Fax:
Practice Address - Street 1:1376 FRUITVALE RD # DAY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-9671
Practice Address - Country:US
Practice Address - Phone:541-265-7945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-28
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)