Provider Demographics
NPI:1558880666
Name:WOODY, HEATHER M (TLLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:WOODY
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:248-620-6400
Mailing Address - Fax:
Practice Address - Street 1:6549 TOWN CENTER DR STE A
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4824
Practice Address - Country:US
Practice Address - Phone:248-620-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
MI6301017644103TC0700X
MI6362004421103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program