Healthcare Provider Details

I. General information

NPI: 1104714401
Provider Name (Legal Business Name): KURT WOODWARD MS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 CAMP PHILLIPS RD
WESTON WI
54476-1572
US

IV. Provider business mailing address

901 N 6TH ST
WAUSAU WI
54403-4718
US

V. Phone/Fax

Practice location:
  • Phone: 715-848-5022
  • Fax: 888-778-6750
Mailing address:
  • Phone: 715-848-5022
  • Fax: 888-778-6750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8547226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: