Provider Demographics
NPI:1497250922
Name:WOODRUFF, ROBERT LINCOLN (ATC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LINCOLN
Last Name:WOODRUFF
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 KILEY DR APT 32
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-9787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 E NORRIS DR STE 3
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1605
Practice Address - Country:US
Practice Address - Phone:815-431-5746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0045132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer