Provider Demographics
NPI:1548580111
Name:WOODBURN, MARY JEAN (MS, LADC, CSAT-S)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JEAN
Last Name:WOODBURN
Suffix:
Gender:F
Credentials:MS, LADC, CSAT-S
Other - Prefix:MS
Other - First Name:MJ
Other - Middle Name:
Other - Last Name:WOODBURN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS, MS, SPECED
Mailing Address - Street 1:1361 POND RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:VT
Mailing Address - Zip Code:05354-9624
Mailing Address - Country:US
Mailing Address - Phone:802-380-3994
Mailing Address - Fax:
Practice Address - Street 1:14 PARK PL
Practice Address - Street 2:SUITE # 3
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-2821
Practice Address - Country:US
Practice Address - Phone:802-380-3994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000267101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)