Healthcare Provider Details

I. General information

NPI: 1235990375
Provider Name (Legal Business Name): WESLEY WOOD MA, ADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 MACCORKLE AVE STE 201
SAINT ALBANS WV
25177-2074
US

IV. Provider business mailing address

2333 MACCORKLE AVE STE 201
SAINT ALBANS WV
25177-2074
US

V. Phone/Fax

Practice location:
  • Phone: 304-419-7252
  • Fax:
Mailing address:
  • Phone: 304-419-7252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23-114
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: