Provider Demographics
NPI:1417403262
Name:WOODY, SHAUNA
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:WOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7050 TERRA CHASE CV
Mailing Address - Street 2:115
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6595
Mailing Address - Country:US
Mailing Address - Phone:682-404-8957
Mailing Address - Fax:
Practice Address - Street 1:1101 YUCCA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111
Practice Address - Country:US
Practice Address - Phone:817-714-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1165572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer