Healthcare Provider Details

I. General information

NPI: 1710856257
Provider Name (Legal Business Name): SAMANTHA GAYLE WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 ELDEN STREET SUITE 302
HERNDON VA
20170
US

IV. Provider business mailing address

313 ELDEN STREET SUITE 302
HERNDON VA
20170
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax:
Mailing address:
  • Phone: 804-562-9997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: