Provider Demographics
NPI:1255422374
Name:WOODWARD, W THOMAS (PHD)
Entity type:Individual
Prefix:
First Name:W
Middle Name:THOMAS
Last Name:WOODWARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 S CREYTS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8234
Mailing Address - Country:US
Mailing Address - Phone:517-323-4099
Mailing Address - Fax:517-323-3334
Practice Address - Street 1:701 S CREYTS RD
Practice Address - Street 2:SUITE C
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8234
Practice Address - Country:US
Practice Address - Phone:517-323-4099
Practice Address - Fax:517-323-3334
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003111103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R77547Medicare UPIN
0B34521Medicare ID - Type Unspecified