Provider Demographics
NPI:1134721996
Name:WOODS, PREVIOUS J (LMT)
Entity type:Individual
Prefix:
First Name:PREVIOUS
Middle Name:J
Last Name:WOODS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:PREVIOUS
Other - Middle Name:J
Other - Last Name:WOODS FAIRLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:810 AIRPORT RD. CANTERBURY
Mailing Address - Street 2:E37
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751
Mailing Address - Country:US
Mailing Address - Phone:662-303-4699
Mailing Address - Fax:
Practice Address - Street 1:131 FRONT ST.
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751
Practice Address - Country:US
Practice Address - Phone:662-303-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2761225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist