Provider Demographics
NPI:1003325200
Name:WOODRUFF, TED (CRM)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:WOODRUFF
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1340
Mailing Address - Country:US
Mailing Address - Phone:541-523-7400
Mailing Address - Fax:541-523-4927
Practice Address - Street 1:3425 13TH ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1340
Practice Address - Country:US
Practice Address - Phone:541-523-7400
Practice Address - Fax:541-523-4927
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14-CRM-024101YA0400X
ORTHW000000864175T00000X
ORT-20-391101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500609571Medicaid
OR14-CRM-024OtherMHACBO CRM