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General NPI Number Information
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NPI Number | 1306685201
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Entity Type | Individual
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Provider Name | WISTERIA JOY WOOD AMFT/APCC
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Gender |
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Dates
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Enumeration Date | 05/21/2024
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 22846 BLACK HAWK DR # B
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City | TWAIN HARTE
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State | CA
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Zip | 95383-9536
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Country | US
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Telephone | 818-205-7738
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Fax |
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Provider Business Mailing Address
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Address Line | 22846 BLACK HAWK DR # B
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City | TWAIN HARTE
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State | CA
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Zip | 95383-9536
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 16457
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 146560
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License Number State | CA
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