MEDICARE: MS. DEBORAH LILLIAS WOODARD MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LISAC-10614	AZ
2	1041C0700X	Clinical Social Worker	LCSW-11889	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	003957	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1134384910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEBORAH LILLIAS WOODARD MSW

Provider Business Mailing Address
First Line	:	10601 N 39TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-3417
Country	:	US
Telephone Number	:	602-290-2684
Fax Number	:

Provider Business Practice Location Address
First Line	:	10601 N 39TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-3417
Country	:	US
Telephone Number	:	602-290-2684
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2008
Last Update Date	:	07/22/2008

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