MEDICARE: MRS. MUNTRELLA REGINA WOODARD MASTERS OF ART

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1467843052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MUNTRELLA REGINA WOODARD MASTERS OF ART

Provider Business Mailing Address
First Line	:	735 N CYPRESS AVE
Second Line	:
City	:	GREEN COVE SPRINGS
State	:	FL
Zip	:	32043-2412
Country	:	US
Telephone Number	:	904-600-1349
Fax Number	:

Provider Business Practice Location Address
First Line	:	580 ELLIS RD S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-3582
Country	:	US
Telephone Number	:	904-423-0017
Fax Number	:	904-683-8169

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

Provider Enumeration Date	:	02/18/2015
Last Update Date	:	02/18/2015

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