Provider Demographics
NPI:1336215102
Name:WOODBURN, LAWRENCE TODD (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:TODD
Last Name:WOODBURN
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 1:5670 DOLPHIN PL
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7517
Mailing Address - Country:US
Mailing Address - Phone:760-434-2242
Mailing Address - Fax:
Practice Address - Street 1:9255 TOWNE CENTRE DR
Practice Address - Street 2:SUITE 370
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3033
Practice Address - Country:US
Practice Address - Phone:760-434-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5312103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL53120Medicaid
CA00PL53120Medicaid
CAR25888Medicare UPIN