Provider Demographics
NPI:1346525987
Name:WOODS, KEDREN
Entity Type:Individual
Prefix:
First Name:KEDREN
Middle Name:
Last Name:WOODS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3824 ASPEN SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-8104
Mailing Address - Country:US
Mailing Address - Phone:702-630-2407
Mailing Address - Fax:702-644-6031
Practice Address - Street 1:3824 ASPEN SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-8104
Practice Address - Country:US
Practice Address - Phone:702-630-2407
Practice Address - Fax:702-644-6031
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid