Provider Demographics
NPI:1124513296
Name:WOOD, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 PULGAS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-1323
Mailing Address - Country:US
Mailing Address - Phone:866-325-6466
Mailing Address - Fax:
Practice Address - Street 1:2560 PULGAS AVE
Practice Address - Street 2:
Practice Address - City:EAST PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-1323
Practice Address - Country:US
Practice Address - Phone:866-325-6466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX596961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW83240OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES
TXLCSW59696OtherTEXAS BOARD OF SOCIAL WORK EXAMINERS