Provider Demographics
NPI:1043184732
Name:WOODBURY, MICHELE JAN (MA, PPSC)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:JAN
Last Name:WOODBURY
Suffix:
Gender:F
Credentials:MA, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 NOVA ALBION WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-6017
Practice Address - Country:US
Practice Address - Phone:415-485-2317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool