Healthcare Provider Details

I. General information

NPI: 1427065689
Provider Name (Legal Business Name): DR. STACEY WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 COLUMBIA AVE STEELE 108
CLAREMONT CA
91711-3905
US

IV. Provider business mailing address

1280 N COLLEGE AVE
CLAREMONT CA
91711-3929
US

V. Phone/Fax

Practice location:
  • Phone: 909-607-9505
  • Fax:
Mailing address:
  • Phone: 909-706-2764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number16805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: