1487613204 NPI number — MS. VALECIA LISA WOODDELL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487613204 NPI number — MS. VALECIA LISA WOODDELL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODDELL
Provider First Name:
VALECIA
Provider Middle Name:
LISA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOODDELL
Provider Other First Name:
LISA
Provider Other Middle Name:
LEFLET
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1487613204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1385
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AHOSKIE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27910-1385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-209-8161
Provider Business Mailing Address Fax Number:
252-209-6011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1112 ACADEMY ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AHOSKIE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27910-2210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-209-8161
Provider Business Practice Location Address Fax Number:
252-209-6011
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C003549 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: E0075 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 12779 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6003004 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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