Basic Information
| Provider Information | |||||||||
| NPI: | 1811063522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | CLARISSA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4127 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240150127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409819394 | ||||||||
| FaxNumber: | 5403447154 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 BRIAR KNOLL CT STE 1 | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229392635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409490955 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904002112 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 143686 | 01 | VA | A TRIGON | OTHER | 343341 | 01 | VA | TRICARE | OTHER | 1859737 | 05 | VA | MEDICAID |