=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922343532
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOBBY J WOOD LCPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2012
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1341 WARREN AVE
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-3437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-719-5454
-----------------------------------------------------
Fax | 630-719-1263
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29373 NETWORK PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-1293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-390-5900
-----------------------------------------------------
Fax | 847-390-4757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180008379
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.008378
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 180.008378
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------