Provider Demographics
NPI:1225877699
Name:WOOD, BANESHA
Entity type:Individual
Prefix:
First Name:BANESHA
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4541
Mailing Address - Country:US
Mailing Address - Phone:281-468-1914
Mailing Address - Fax:
Practice Address - Street 1:2355 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:281-468-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX96627101YM0800X
ORR10325101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health