Provider Demographics
NPI:1780899609
Name:WOODALL, RENEE ANDRADE (PHD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:ANDRADE
Last Name:WOODALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 REDWING RD STE 316
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2879
Mailing Address - Country:US
Mailing Address - Phone:970-556-5836
Mailing Address - Fax:970-837-3352
Practice Address - Street 1:2629 REDWING RD STE 316
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2879
Practice Address - Country:US
Practice Address - Phone:970-556-5836
Practice Address - Fax:970-837-3352
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0700X, 103TB0200X, 103T00000X, 103TH0004X
CO3173103TC1900X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO307368Medicare PIN