Healthcare Provider Details

I. General information

NPI: 1043575400
Provider Name (Legal Business Name): MARK WOODS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MARKET AVE N
CANTON OH
44702-1017
US

IV. Provider business mailing address

15582 DOVER RD
DALTON OH
44618-9144
US

V. Phone/Fax

Practice location:
  • Phone: 330-454-7066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1100033-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: