Provider Demographics
NPI:1184250672
Name:WOOD, LESLIE (CDCA171476)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:CDCA171476
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2538
Mailing Address - Country:US
Mailing Address - Phone:740-442-7044
Mailing Address - Fax:
Practice Address - Street 1:2117 S 7TH ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2538
Practice Address - Country:US
Practice Address - Phone:606-442-7044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHQMHS101YM0800X
OHCDCA.171476101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0395302Medicaid