Provider Demographics
NPI:1760997464
Name:WOODVINE, CAROL DENISE (M,OTR/L)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:DENISE
Last Name:WOODVINE
Suffix:
Gender:F
Credentials:M,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2177 MORENCY DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9516
Mailing Address - Country:US
Mailing Address - Phone:208-317-4440
Mailing Address - Fax:
Practice Address - Street 1:913 HORNE DRIVE
Practice Address - Street 2:
Practice Address - City:BENTON CITY
Practice Address - State:WA
Practice Address - Zip Code:99320
Practice Address - Country:US
Practice Address - Phone:509-588-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003399225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics