Provider Demographics
NPI:1821586504
Name:WOODYARD, ELISHA ANN (LCDC III)
Entity Type:Individual
Prefix:MRS
First Name:ELISHA
Middle Name:ANN
Last Name:WOODYARD
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2815
Mailing Address - Country:US
Mailing Address - Phone:937-376-8700
Mailing Address - Fax:937-376-8725
Practice Address - Street 1:452 W MARKET ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2815
Practice Address - Country:US
Practice Address - Phone:937-376-8700
Practice Address - Fax:937-376-8725
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161361101YA0400X
OHC2002217-TRNE390200000X
OHC2103747101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid