Provider Demographics
NPI:1285300079
Name:WOODALL, MARY RUTH (BCBA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:RUTH
Last Name:WOODALL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7552 NAVARRE PKWY UNIT 32
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-7308
Mailing Address - Country:US
Mailing Address - Phone:850-939-3944
Mailing Address - Fax:
Practice Address - Street 1:7552 NAVARRE PKWY UNIT 32
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7308
Practice Address - Country:US
Practice Address - Phone:850-939-3944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13435106E00000X
FLRBT-21-179915106S00000X
FL1-24-77490103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician