Provider Demographics
NPI:1316618176
Name:WOOD, MARISA KAITLYN (CMT)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:KAITLYN
Last Name:WOOD
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:RISA
Other - Middle Name:KAITLYN
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMT
Mailing Address - Street 1:1002 E 23RD ST APT 4
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-2742
Mailing Address - Country:US
Mailing Address - Phone:925-951-7313
Mailing Address - Fax:
Practice Address - Street 1:1025 B ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4107
Practice Address - Country:US
Practice Address - Phone:510-733-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81728225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81728OtherCAMTC