Provider Demographics
NPI:1457715070
Name:WOODBERRY, LADESSEA MORNAE
Entity Type:Individual
Prefix:
First Name:LADESSEA
Middle Name:MORNAE
Last Name:WOODBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E WINTERGREEN RD
Mailing Address - Street 2:APT 3204
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2496
Mailing Address - Country:US
Mailing Address - Phone:469-652-5125
Mailing Address - Fax:
Practice Address - Street 1:190 CIVIC CIR STE 210
Practice Address - Street 2:SUITE 210
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3635
Practice Address - Country:US
Practice Address - Phone:972-219-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-09
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program