=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730369208
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA WOODS M.S.W, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2007
-----------------------------------------------------
Last Update Date | 03/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 RIDGE RD SUITE 1SW
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60430-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-794-6511
-----------------------------------------------------
Fax | 708-249-0022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 RIDGE RD SUITE 1SW
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60430-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-794-6511
-----------------------------------------------------
Fax | 708-249-0022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149-013839
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------