Provider Demographics
NPI:1093346371
Name:WOODSON, TALLIE SEPTEMBER
Entity Type:Individual
Prefix:
First Name:TALLIE
Middle Name:SEPTEMBER
Last Name:WOODSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-5595
Mailing Address - Country:US
Mailing Address - Phone:818-438-3424
Mailing Address - Fax:
Practice Address - Street 1:601 E 18TH ST
Practice Address - Street 2:
Practice Address - City:LA CENTER
Practice Address - State:WA
Practice Address - Zip Code:98629-5595
Practice Address - Country:US
Practice Address - Phone:818-438-3424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer