Healthcare Provider Details

I. General information

NPI: 1316234990
Provider Name (Legal Business Name): REBECCA IRENE WOODY LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 MESA BLVD SUITE D
GRANTS NM
87020-3038
US

IV. Provider business mailing address

1109 MESA BLVD SUITE D
GRANTS NM
87020-3038
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-3773
  • Fax: 505-287-5011
Mailing address:
  • Phone: 505-287-3773
  • Fax: 505-287-5011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0116971
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: