Provider Demographics
NPI:1205982279
Name:WOODWARD, MARY (MA, LP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:WOODWARD
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 LEXINGTON AVE S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2276
Mailing Address - Country:US
Mailing Address - Phone:651-454-4343
Mailing Address - Fax:651-454-9494
Practice Address - Street 1:3345 LEXINGTON AVE S
Practice Address - Street 2:SUITE 102
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-2276
Practice Address - Country:US
Practice Address - Phone:651-454-4343
Practice Address - Fax:651-454-9494
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3003103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily