Provider Demographics
NPI:1154720183
Name:WOODARD, COLLEEN (CDAC-1)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WOODARD
Suffix:
Gender:F
Credentials:CDAC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23119 COTTONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-9661
Mailing Address - Country:US
Mailing Address - Phone:951-413-5130
Mailing Address - Fax:951-413-5230
Practice Address - Street 1:31764 CASINO DR STE 200
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2312
Practice Address - Country:US
Practice Address - Phone:909-573-7618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACICA00670319101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator