Provider Demographics
NPI:1235679895
Name:WOODALL, CLIFFORD S (BCBA, SSW)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:S
Last Name:WOODALL
Suffix:
Gender:M
Credentials:BCBA, SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6013 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5220
Mailing Address - Country:US
Mailing Address - Phone:801-255-5131
Mailing Address - Fax:801-255-5131
Practice Address - Street 1:6013 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5220
Practice Address - Country:US
Practice Address - Phone:801-255-5131
Practice Address - Fax:801-255-5131
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT3107107-3503104100000X
UT3107107-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty