Healthcare Provider Details

I. General information

NPI: 1669777561
Provider Name (Legal Business Name): SUSAN MCCULLOUGH WOOD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 4TH ST S
FARGO ND
58103-1929
US

IV. Provider business mailing address

700 1ST AVE S
FARGO ND
58103-1802
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3100
  • Fax:
Mailing address:
  • Phone: 701-234-4021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number457
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: