Provider Demographics
NPI:1457092967
Name:WOODEN, DYMECOH EASTLIN
Entity Type:Individual
Prefix:
First Name:DYMECOH
Middle Name:EASTLIN
Last Name:WOODEN
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 1:401 APRICOT ST
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-2561
Mailing Address - Country:US
Mailing Address - Phone:540-429-7088
Mailing Address - Fax:
Practice Address - Street 1:27777 INKSTER RD STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5312
Practice Address - Country:US
Practice Address - Phone:248-436-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician