Provider Demographics
NPI:1346288909
Name:WOODRUFF, MYRA ELAINE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:ELAINE
Last Name:WOODRUFF
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 OUTLOOK LN
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-2532
Mailing Address - Country:US
Mailing Address - Phone:802-861-2318
Mailing Address - Fax:802-899-4880
Practice Address - Street 1:3 MAIN ST
Practice Address - Street 2:SUITE 216
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5216
Practice Address - Country:US
Practice Address - Phone:802-651-2318
Practice Address - Fax:801-899-4880
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2008-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900009191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009230Medicaid
VT0003407Medicare PIN