Provider Demographics
NPI:1477947232
Name:WOODSON, LORENZO ADRIAN
Entity Type:Individual
Prefix:DR
First Name:LORENZO
Middle Name:ADRIAN
Last Name:WOODSON
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 1:121 WEST WYNEVA STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144
Mailing Address - Country:US
Mailing Address - Phone:267-632-1068
Mailing Address - Fax:
Practice Address - Street 1:121 W WYNEVA ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-3631
Practice Address - Country:US
Practice Address - Phone:267-632-1068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH000181103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA821253172Medicaid