Provider Demographics
NPI:1114791225
Name:WOODWORTH, LYNNIESSA
Entity Type:Individual
Prefix:
First Name:LYNNIESSA
Middle Name:
Last Name:WOODWORTH
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 1:1123 E WHITTIER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-3140
Mailing Address - Country:US
Mailing Address - Phone:614-374-6127
Mailing Address - Fax:
Practice Address - Street 1:40 S JAMES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1696
Practice Address - Country:US
Practice Address - Phone:614-534-0951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTZ960955172A00000X
251C00000X, 3104A0625X, 320600000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities