Provider Demographics
NPI:1699289926
Name:WOODWORTH PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:WOODWORTH PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WOODWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:612-206-2735
Mailing Address - Street 1:1405 LILAC DR N STE 200
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4546
Mailing Address - Country:US
Mailing Address - Phone:763-545-7708
Mailing Address - Fax:763-545-3479
Practice Address - Street 1:1405 LILAC DR N STE 200
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4546
Practice Address - Country:US
Practice Address - Phone:763-545-7708
Practice Address - Fax:763-545-3479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6072103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty