Provider Demographics
NPI:1114478443
Name:WOODBERRY, CHAQUITA
Entity Type:Individual
Prefix:
First Name:CHAQUITA
Middle Name:
Last Name:WOODBERRY
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 1:9705 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-3511
Mailing Address - Country:US
Mailing Address - Phone:405-532-9843
Mailing Address - Fax:
Practice Address - Street 1:9705 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-3511
Practice Address - Country:US
Practice Address - Phone:405-532-9843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK081534729101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health