MEDICARE: DEADRA DENISE WOOLBRIGHT MFT

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		CA

General Provider Information

NPI Number	:	1659890457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEADRA DENISE WOOLBRIGHT MFT

Provider Business Mailing Address
First Line	:	PO BOX 5762
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95205-0762
Country	:	US
Telephone Number	:	209-248-0535
Fax Number	:

Provider Business Practice Location Address
First Line	:	2254 E CHURCH ST
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95205-6407
Country	:	US
Telephone Number	:	209-248-0535
Fax Number	:

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

Provider Enumeration Date	:	09/12/2017
Last Update Date	:	06/16/2018

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