MEDICARE: MR. MAX L WOOD LCSW

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	1041C0700X	Clinical Social Worker	149004660	IL

General Provider Information

NPI Number	:	1962630442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MAX L WOOD LCSW

Provider Business Mailing Address
First Line	:	6400 W MAIN ST
Second Line	:	SUITE 1-S
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3806
Country	:	US
Telephone Number	:	618-394-9282
Fax Number	:

Provider Business Practice Location Address
First Line	:	6400 W MAIN ST
Second Line	:	SUITE 1-S
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3806
Country	:	US
Telephone Number	:	618-394-9282
Fax Number	:

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

Provider Enumeration Date	:	06/23/2009
Last Update Date	:	06/23/2009

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