Provider Demographics
NPI:1548393820
Name:WOOTEN, MARA (MSW)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4328 BLAND RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6125
Mailing Address - Country:US
Mailing Address - Phone:919-341-3894
Mailing Address - Fax:
Practice Address - Street 1:4328 BLAND RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6125
Practice Address - Country:US
Practice Address - Phone:919-341-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300173KMedicaid