Healthcare Provider Details

I. General information

NPI: 1972141752
Provider Name (Legal Business Name): HALEY KAI WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W COTA ST
SHELTON WA
98584-2265
US

IV. Provider business mailing address

307 W COTA ST
SHELTON WA
98584-2265
US

V. Phone/Fax

Practice location:
  • Phone: 360-427-2575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: