Provider Demographics
NPI:1982940136
Name:WOOD, LUSHUNDA LAKETA (LISW-CP)
Entity Type:Individual
Prefix:
First Name:LUSHUNDA
Middle Name:LAKETA
Last Name:WOOD
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 HUNTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-2780
Mailing Address - Country:US
Mailing Address - Phone:864-256-0934
Mailing Address - Fax:
Practice Address - Street 1:2375 E MAIN ST STE A105-110
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1434
Practice Address - Country:US
Practice Address - Phone:864-256-0934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC124709OtherSOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE