Provider Demographics
NPI:1457843435
Name:WOODBURY, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WOODBURY
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 1:2143 PINNACLE ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2342
Mailing Address - Country:US
Mailing Address - Phone:803-378-4205
Mailing Address - Fax:
Practice Address - Street 1:1512 AMELIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-6077
Practice Address - Country:US
Practice Address - Phone:803-347-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6415101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional