Provider Demographics
NPI:1023110509
Name:WOODSON, MELISSA LEA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:LEA
Last Name:WOODSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5007 LAVENDER LEAF
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-0600
Mailing Address - Country:US
Mailing Address - Phone:903-759-1043
Mailing Address - Fax:903-759-0897
Practice Address - Street 1:5007 LAVENDER LEAF
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-0600
Practice Address - Country:US
Practice Address - Phone:903-759-1043
Practice Address - Fax:903-759-0897
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177695701Medicaid
TXP00315110OtherRAILROAD MEDICARE
TXP00315110OtherRAILROAD MEDICARE