Provider Demographics
NPI:1801084413
Name:WOODARD, SHIRLEY M (DEVELOPMENTAL THERAP)
Entity type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:M
Last Name:WOODARD
Suffix:
Gender:F
Credentials:DEVELOPMENTAL THERAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 FOSTER RD
Mailing Address - Street 2:P. O. BOX 38
Mailing Address - City:ULLIN
Mailing Address - State:IL
Mailing Address - Zip Code:62992-2321
Mailing Address - Country:US
Mailing Address - Phone:618-845-9248
Mailing Address - Fax:618-845-9248
Practice Address - Street 1:221 FOSTER RD
Practice Address - Street 2:
Practice Address - City:ULLIN
Practice Address - State:IL
Practice Address - Zip Code:62992-2321
Practice Address - Country:US
Practice Address - Phone:618-845-9248
Practice Address - Fax:618-845-9248
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILSW86551101P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist