Provider Demographics
NPI:1245691773
Name:WOODBURY LEADERSHIP ACADEMY 4228-07
Entity type:Organization
Organization Name:WOODBURY LEADERSHIP ACADEMY 4228-07
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPECIAL EDUCATION
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-325-2268
Mailing Address - Street 1:600 WEIR DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1240
Mailing Address - Country:US
Mailing Address - Phone:612-325-2268
Mailing Address - Fax:
Practice Address - Street 1:600 WEIR DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1240
Practice Address - Country:US
Practice Address - Phone:612-325-2268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health