Provider Demographics
NPI:1346560869
Name:JOHN O. WOOD PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:JOHN O. WOOD PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:573-778-3913
Mailing Address - Street 1:1906 GREENWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2430
Mailing Address - Country:US
Mailing Address - Phone:573-778-3913
Mailing Address - Fax:573-778-0925
Practice Address - Street 1:1906 GREENWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2430
Practice Address - Country:US
Practice Address - Phone:573-778-3913
Practice Address - Fax:573-778-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01540251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493461404Medicaid