Provider Demographics
NPI:1164465084
Name:WOOD, KELLE S (LMSW)
Entity type:Individual
Prefix:
First Name:KELLE
Middle Name:S
Last Name:WOOD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3905
Mailing Address - Country:US
Mailing Address - Phone:810-357-9318
Mailing Address - Fax:810-479-9684
Practice Address - Street 1:3071 COMMERCE DR STE B
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3869
Practice Address - Country:US
Practice Address - Phone:810-357-9318
Practice Address - Fax:810-479-9684
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97240035Medicare ID - Type Unspecified