Provider Demographics
NPI:1164507349
Name:WOODLAND, LARRY ANTONIO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ANTONIO
Last Name:WOODLAND
Suffix:
Gender:M
Credentials:LCSW
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Other - First Name:
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Mailing Address - Street 1:821 S GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3449
Mailing Address - Country:US
Mailing Address - Phone:510-387-7965
Mailing Address - Fax:213-632-3192
Practice Address - Street 1:627 N LARCHMONT BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-1307
Practice Address - Country:US
Practice Address - Phone:510-387-7965
Practice Address - Fax:213-632-3192
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0758021041C0700X
CA635661041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA83-2560750Medicaid