Provider Demographics
NPI:1902352271
Name:WOOD, MARY (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51322
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5622
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:
Practice Address - Street 1:17 CALEDON CT
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3170
Practice Address - Country:US
Practice Address - Phone:864-631-2084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11622552103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst