Provider Demographics
NPI:1659187490
Name:WOOLHEATER, JOHNATHAN
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:WOOLHEATER
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:WOOLHEATER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:690 CLEVELAND AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1319
Mailing Address - Country:US
Mailing Address - Phone:651-493-8412
Mailing Address - Fax:
Practice Address - Street 1:690 CLEVELAND AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1319
Practice Address - Country:US
Practice Address - Phone:651-493-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician