Provider Demographics
NPI:1801561774
Name:WOOD, KELLY (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 62ND ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2322
Mailing Address - Country:US
Mailing Address - Phone:815-528-2046
Mailing Address - Fax:
Practice Address - Street 1:1140 N MCLEAN BLVD # 1
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1782
Practice Address - Country:US
Practice Address - Phone:847-695-3680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist