=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568953131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA WOODBURN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2018
-----------------------------------------------------
Last Update Date | 05/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 NE 4TH AVE
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33305-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-322-1163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 NE 17TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33304-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-647-1139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW3034
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------