=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417174020
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOE D WOOD JR. PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11160 SW WOOD DUCK PL
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97007-8295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-329-9195
-----------------------------------------------------
Fax | 503-521-1593
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4900 SW GRIFFITH DR SUITE 261
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-4648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-329-9195
-----------------------------------------------------
Fax | 503-521-1593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1179
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------