Healthcare Provider Details

I. General information

NPI: 1174740252
Provider Name (Legal Business Name): MICHAEL WOODIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 N J ST
RICHMOND IN
47374-1913
US

IV. Provider business mailing address

1100 REID PARKWAY MEDICAL STAFF SERVICES
RICHMOND IN
47374
US

V. Phone/Fax

Practice location:
  • Phone: 765-983-3298
  • Fax: 765-983-7970
Mailing address:
  • Phone: 765-935-8802
  • Fax: 765-983-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20042068A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP.07823
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20042068B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: