Healthcare Provider Details

I. General information

NPI: 1801561774
Provider Name (Legal Business Name): KELLY WOOD MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/12/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 N MCLEAN BLVD # 1
ELGIN IL
60123-1782
US

IV. Provider business mailing address

996 62ND ST UNIT B
OAKLAND CA
94608-2322
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-3680
  • Fax:
Mailing address:
  • Phone: 815-528-2046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: