Healthcare Provider Details

I. General information

NPI: 1891440558
Provider Name (Legal Business Name): OLIVIA ROSE WOODWARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 AMERICAN BLVD E STE 8
BLOOMINGTON MN
55425-1230
US

IV. Provider business mailing address

4701 EMERSON AVE S
MINNEAPOLIS MN
55419-5329
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-2267
  • Fax:
Mailing address:
  • Phone: 612-704-3231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: