Healthcare Provider Details

I. General information

NPI: 1316147317
Provider Name (Legal Business Name): CAROL A WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N MAIN ST
DECATUR IL
62523-1206
US

IV. Provider business mailing address

PO BOX 710
DECATUR IL
62525-0710
US

V. Phone/Fax

Practice location:
  • Phone: 217-362-6262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number309-003503
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: