Provider Demographics
NPI:1881811875
Name:WOOD, JOHN E (LADC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:WOOD
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 TANDBERG TRL UNIT 2A
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5205
Mailing Address - Country:US
Mailing Address - Phone:207-893-8544
Mailing Address - Fax:207-893-8545
Practice Address - Street 1:76 TANDBERG TRL UNIT 2A
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062
Practice Address - Country:US
Practice Address - Phone:207-893-8544
Practice Address - Fax:207-893-8545
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3703101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1881811875Medicaid