Provider Demographics
NPI:1194307868
Name:WOOD, BERNADETTE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10339 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-0620
Mailing Address - Country:US
Mailing Address - Phone:708-302-0247
Mailing Address - Fax:
Practice Address - Street 1:1595 S CALUMET RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2389
Practice Address - Country:US
Practice Address - Phone:219-764-4888
Practice Address - Fax:219-898-4258
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006287235Z00000X
22007875235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196020AMedicaid