=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366841157
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY WOOD LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2014
-----------------------------------------------------
Last Update Date | 08/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 GREEN MOR CT APT 1
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21804-6206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-245-4265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5664 CLARK RD
-----------------------------------------------------
City | CONESUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14435-9592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-245-4265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | A0000526
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------