Healthcare Provider Details

I. General information

NPI: 1063239176
Provider Name (Legal Business Name): MICHAEL WOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2024
Last Update Date: 09/21/2024
Certification Date: 09/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 17TH ST
BOULDER CO
80302-7636
US

IV. Provider business mailing address

637 17TH ST
BOULDER CO
80302-7636
US

V. Phone/Fax

Practice location:
  • Phone: 847-702-9164
  • Fax:
Mailing address:
  • Phone: 847-702-9164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC.0022206
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: