MEDICARE: MR. ERIC WOOD MA, LCAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	87000353A	IN

General Provider Information

NPI Number	:	1871854992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ERIC WOOD MA, LCAC

Provider Business Mailing Address
First Line	:	1803 BROAD RIPPLE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2339
Country	:	US
Telephone Number	:	317-726-0777
Fax Number	:	317-726-0779

Provider Business Practice Location Address
First Line	:	1803 BROAD RIPPLE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2339
Country	:	US
Telephone Number	:	317-726-0777
Fax Number	:	317-726-0779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2012
Last Update Date	:	06/05/2012

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