Provider Demographics
NPI:1609402957
Name:WOODSIDE, BRIAN (CIP, ICRC-ADC, CAC,)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WOODSIDE
Suffix:
Gender:M
Credentials:CIP, ICRC-ADC, CAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 SWEETGRASS ST
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-6127
Mailing Address - Country:US
Mailing Address - Phone:561-376-6685
Mailing Address - Fax:
Practice Address - Street 1:915 SWEETGRASS ST
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-6127
Practice Address - Country:US
Practice Address - Phone:561-376-6685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAC100072101YA0400X
FLCET100015101YA0400X
FLCRSS100026101YA0400X
PAI0181101YA0400X
FL806449101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)