Provider Demographics
NPI:1033742226
Name:WOODALL, RAPHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:WOODALL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6819 KERRI VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-2848
Mailing Address - Country:US
Mailing Address - Phone:662-832-0933
Mailing Address - Fax:
Practice Address - Street 1:4646 POPLAR AVE STE 302
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4433
Practice Address - Country:US
Practice Address - Phone:901-930-7397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000059981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical