Provider Demographics
NPI:1154869089
Name:WOOD, KRISTIN TIEDEKEN (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:TIEDEKEN
Last Name:WOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LOGAN SQ STE 300
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-2733
Mailing Address - Country:US
Mailing Address - Phone:484-318-9151
Mailing Address - Fax:
Practice Address - Street 1:2 LOGAN SQ STE 300
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-2733
Practice Address - Country:US
Practice Address - Phone:484-318-9151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-12
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0167401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical