Provider Demographics
NPI:1154375236
Name:WOODLAKE PSYCHOLOGICAL AND PSYCHIATRIC ASSOCIATES, PLLC
Entity type:Organization
Organization Name:WOODLAKE PSYCHOLOGICAL AND PSYCHIATRIC ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:STONE
Authorized Official - Last Name:POLINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:336-889-6800
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-0772
Mailing Address - Country:US
Mailing Address - Phone:336-889-6800
Mailing Address - Fax:336-889-6800
Practice Address - Street 1:725 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282-7506
Practice Address - Country:US
Practice Address - Phone:336-889-6800
Practice Address - Fax:336-889-6800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-21
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1242103TC0700X
NCCOOO6661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1154375236Medicare UPIN