Provider Demographics
NPI:1639346125
Name:WOODS, MARY ANN (DT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:WOODS
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:8021 W STUENKEL RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-8041
Mailing Address - Country:US
Mailing Address - Phone:815-464-9585
Mailing Address - Fax:815-464-1516
Practice Address - Street 1:8309 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-8602
Practice Address - Country:US
Practice Address - Phone:847-890-1227
Practice Address - Fax:815-464-5466
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1000444156276201222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1000444156276201Medicaid