Provider Demographics
NPI:1497165146
Name:SONG, WOOJIN (PHD)
Entity Type:Individual
Prefix:
First Name:WOOJIN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 COMMONWEALTH BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2969
Mailing Address - Country:US
Mailing Address - Phone:608-217-6369
Mailing Address - Fax:734-936-9262
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:312-996-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-03
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015267103G00000X
IL071008770103TC0700X
IL071.008770103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical