Provider Demographics
NPI:1952454225
Name:WOODWARD, MARIE CANNON (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:CANNON
Last Name:WOODWARD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 HIGHWAY 17 S
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-3948
Mailing Address - Country:US
Mailing Address - Phone:843-457-1804
Mailing Address - Fax:843-272-2460
Practice Address - Street 1:1602 HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3948
Practice Address - Country:US
Practice Address - Phone:843-457-1804
Practice Address - Fax:843-272-2460
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1919101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional