Provider Demographics
NPI:1154665511
Name:WOODY, LATOYA NICHOLE (CASE MANAGE 1)
Entity type:Individual
Prefix:MISS
First Name:LATOYA
Middle Name:NICHOLE
Last Name:WOODY
Suffix:
Gender:F
Credentials:CASE MANAGE 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 N CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4822
Mailing Address - Country:US
Mailing Address - Phone:405-968-2413
Mailing Address - Fax:
Practice Address - Street 1:4501 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4822
Practice Address - Country:US
Practice Address - Phone:405-968-2413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-23
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1154665511Medicaid