Provider Demographics
NPI:1467584680
Name:WOODARD, SHIRLEY BASCOM (PHD, MSW)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:BASCOM
Last Name:WOODARD
Suffix:
Gender:F
Credentials:PHD, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13318 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-9731
Mailing Address - Country:US
Mailing Address - Phone:352-243-9733
Mailing Address - Fax:
Practice Address - Street 1:450 E HIGHWAY 50 STE 6
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2581
Practice Address - Country:US
Practice Address - Phone:352-243-9733
Practice Address - Fax:352-241-9299
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL36581041C0700X
NH6821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ9092OtherBLUE CROSS BLUE SHIELD
FLE2101Medicare ID - Type Unspecified