Provider Demographics
NPI:1376677781
Name:WOODARD, BRIAN RANDOLPH
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:RANDOLPH
Last Name:WOODARD
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 1:4731 WOODCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-4667
Mailing Address - Country:US
Mailing Address - Phone:423-288-2751
Mailing Address - Fax:
Practice Address - Street 1:113 CASSELL DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3775
Practice Address - Country:US
Practice Address - Phone:423-246-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1566224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant