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: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 N 2ND ST
ROGERS AR
72756-6647
US

IV. Provider business mailing address

324 N 2ND ST
ROGERS AR
72756-6647
US

V. Phone/Fax

Practice location:
  • Phone: 479-986-0566
  • Fax: 479-986-0599
Mailing address:
  • Phone: 479-986-0566
  • Fax: 479-986-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: