Provider Demographics
NPI:1376659177
Name:WOODY, DENNIS J (PH D)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:J
Last Name:WOODY
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W HAYS STREET
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-395-0041
Mailing Address - Fax:208-343-4458
Practice Address - Street 1:1310 W HAYS STREET
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-395-0041
Practice Address - Fax:208-343-4458
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY276103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010016343OtherREGENCE BLUE SHIELD
IDN2761OtherBLUE CROSS OF IDAHO
1680599Medicare ID - Type Unspecified