Provider Demographics
NPI:1467843052
Name:WOODARD, MUNTRELLA REGINA (MASTERS OF ART)
Entity type:Individual
Prefix:MRS
First Name:MUNTRELLA
Middle Name:REGINA
Last Name:WOODARD
Suffix:
Gender:F
Credentials:MASTERS OF ART
Other - Prefix:MS
Other - First Name:MUNTRELLA
Other - Middle Name:REGINA
Other - Last Name:FORBES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASTERS OF SCIENCE
Mailing Address - Street 1:735 N CYPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-2412
Mailing Address - Country:US
Mailing Address - Phone:904-600-1349
Mailing Address - Fax:
Practice Address - Street 1:580 ELLIS RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3582
Practice Address - Country:US
Practice Address - Phone:904-423-0017
Practice Address - Fax:904-683-8169
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health