Provider Demographics
NPI:1952736381
Name:WOOD, KATELYN MARIE (MS LPC)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:WOOD
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:MISDOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS LPC
Mailing Address - Street 1:1801 FOX DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7236
Mailing Address - Country:US
Mailing Address - Phone:217-693-4572
Mailing Address - Fax:217-398-0172
Practice Address - Street 1:1801 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7236
Practice Address - Country:US
Practice Address - Phone:217-693-4572
Practice Address - Fax:217-398-0172
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007778101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional