MEDICARE: PROF. LISA FORTLOUIS WOOD PH.D.

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	103TC0700X	Clinical Psychologist	WA 1504	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WA1504	OTHER	WA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1972659159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. LISA FORTLOUIS WOOD PH.D.

Provider Business Mailing Address
First Line	:	16040 CHRISTENSEN RD STE 217
Second Line	:
City	:	TUKWILA
State	:	WA
Zip	:	98188-2966
Country	:	US
Telephone Number	:	206-244-9959
Fax Number	:

Provider Business Practice Location Address
First Line	:	16040 CHRISTENSEN RD STE 217
Second Line	:
City	:	TUKWILA
State	:	WA
Zip	:	98188-2966
Country	:	US
Telephone Number	:	206-244-9959
Fax Number	:

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

Provider Enumeration Date	:	01/28/2007
Last Update Date	:	07/09/2007

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