Provider Demographics
NPI:1689112906
Name:WOODEN, GRANT ALLEN
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:ALLEN
Last Name:WOODEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354A BROWN ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-2934
Mailing Address - Country:US
Mailing Address - Phone:707-718-7746
Mailing Address - Fax:
Practice Address - Street 1:354A BROWN ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-2934
Practice Address - Country:US
Practice Address - Phone:707-718-7746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician