Provider Demographics
NPI:1780747477
Name:WOOD, KEVIN N (MMFT,LPC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:N
Last Name:WOOD
Suffix:
Gender:M
Credentials:MMFT,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 CRESTLINE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716
Mailing Address - Country:US
Mailing Address - Phone:307-688-5000
Mailing Address - Fax:307-688-5015
Practice Address - Street 1:501 S. BURMA AVENUE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82717-3011
Practice Address - Country:US
Practice Address - Phone:307-688-5000
Practice Address - Fax:307-688-5015
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC 888101YP2500X
WYLPC888101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor