Provider Demographics
NPI:1316544950
Name:WOODLOCK, AGNES MARY
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:MARY
Last Name:WOODLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 COLUMBUS AVE UNIT 646
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6008
Mailing Address - Country:US
Mailing Address - Phone:847-346-9858
Mailing Address - Fax:
Practice Address - Street 1:80 NEWBRIDGE WAY
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-7028
Practice Address - Country:US
Practice Address - Phone:847-346-9858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2242451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA224245OtherSOCIAL WORK LICENSE