Provider Demographics
NPI:1316957087
Name:WOODRUM-LEUTHOLD, DIANE (EDD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:WOODRUM-LEUTHOLD
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:WOODRUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:1445 STEWARTSTOWN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3868
Mailing Address - Country:US
Mailing Address - Phone:304-598-2300
Mailing Address - Fax:304-598-2307
Practice Address - Street 1:1445 STEWARTSTOWN RD STE 200
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3868
Practice Address - Country:US
Practice Address - Phone:304-598-2300
Practice Address - Fax:304-598-2307
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20046103TS0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0166166000Medicaid
WV001713032OtherMT. STATE BC/BS