Provider Demographics
NPI:1043001076
Name:WOODWARD, MIKAELA THERISE
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:THERISE
Last Name:WOODWARD
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 YELLOWFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-6817
Mailing Address - Country:US
Mailing Address - Phone:720-969-8680
Mailing Address - Fax:
Practice Address - Street 1:168 YELLOWFIELD WAY
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516-6817
Practice Address - Country:US
Practice Address - Phone:720-969-8680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-17
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool