Provider Demographics
NPI:1811595515
Name:WOODBERRY, SHAUNTRICE
Entity Type:Individual
Prefix:
First Name:SHAUNTRICE
Middle Name:
Last Name:WOODBERRY
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 1:4003 W STAN SCHLUETER LOOP STE 3
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-6120
Mailing Address - Country:US
Mailing Address - Phone:254-630-1578
Mailing Address - Fax:
Practice Address - Street 1:4003 W STAN SCHLUETER LOOP STE 3
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6120
Practice Address - Country:US
Practice Address - Phone:254-630-1578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-20-117408106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician