1548580111 NPI number — MS. MARY JEAN WOODBURN MS, LADC, CSAT-S

Table of content: MS. MARY JEAN WOODBURN MS, LADC, CSAT-S (NPI 1548580111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548580111 NPI number — MS. MARY JEAN WOODBURN MS, LADC, CSAT-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODBURN
Provider First Name:
MARY
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LADC, CSAT-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOODBURN
Provider Other First Name:
MJ
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
BS, MS, SPECED
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1548580111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1361 POND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERNON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05354-9624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-380-3994
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 PARK PL
Provider Second Line Business Practice Location Address:
SUITE # 3
Provider Business Practice Location Address City Name:
BRATTLEBORO
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05301-2821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-380-3994
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2010

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: 101YA0400X , with the licence number:  000267 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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