Provider Demographics
NPI:1306685201
Name:WOOD, WISTERIA JOY (AMFT/APCC)
Entity type:Individual
Prefix:
First Name:WISTERIA
Middle Name:JOY
Last Name:WOOD
Suffix:
Gender:X
Credentials:AMFT/APCC
Other - Prefix:
Other - First Name:WISTERIA
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22846 BLACK HAWK DR # B
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22846 BLACK HAWK DR # B
Practice Address - Street 2:
Practice Address - City:TWAIN HARTE
Practice Address - State:CA
Practice Address - Zip Code:95383-9536
Practice Address - Country:US
Practice Address - Phone:818-205-7738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16457101YP2500X
CA146560106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional