Provider Demographics
NPI:1568953131
Name:WOODBURN, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WOODBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 NE 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3420
Mailing Address - Country:US
Mailing Address - Phone:954-647-1139
Mailing Address - Fax:
Practice Address - Street 1:1600 NE 4TH AVE
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-3002
Practice Address - Country:US
Practice Address - Phone:754-322-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW30341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical