Provider Demographics
NPI:1801879234
Name:WOOLEY, LARRY GEORGE (PSYD, HSPP)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:GEORGE
Last Name:WOOLEY
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 N HARRISON ST
Mailing Address - Street 2:ATTN: ANNE LAWSON
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3163
Mailing Address - Country:US
Mailing Address - Phone:574-267-7169
Mailing Address - Fax:574-268-2377
Practice Address - Street 1:119 W MARKET ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-2311
Practice Address - Country:US
Practice Address - Phone:260-248-8176
Practice Address - Fax:260-248-2366
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041608A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200307900AMedicaid
IN169430AMedicare ID - Type UnspecifiedPROVIDER ID