Healthcare Provider Details

I. General information

NPI: 1942257563
Provider Name (Legal Business Name): MARIE WISEMAN WOOD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N EAST AVE
FAYETTEVILLE AR
72701-5296
US

IV. Provider business mailing address

PO BOX 4808
FAYETTEVILLE AR
72702-4808
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-9696
  • Fax:
Mailing address:
  • Phone: 479-521-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number33129
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number95-308788-2501
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number06-01P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: