Provider Demographics
NPI:1215253620
Name:WOOD, ANTHONY JEROME (NCC, LPC-S)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JEROME
Last Name:WOOD
Suffix:
Gender:
Credentials:NCC, LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8626 AIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2603
Mailing Address - Country:US
Mailing Address - Phone:662-772-5937
Mailing Address - Fax:662-772-5940
Practice Address - Street 1:8626 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2603
Practice Address - Country:US
Practice Address - Phone:662-772-5937
Practice Address - Fax:662-772-5940
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1326101YM0800X, 101YP2500X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center