Provider Demographics
NPI:1134883804
Name:WOODWORTH, KIANA MARIE
Entity type:Individual
Prefix:
First Name:KIANA
Middle Name:MARIE
Last Name:WOODWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 CHRISTIAN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-3210
Mailing Address - Country:US
Mailing Address - Phone:207-922-4600
Mailing Address - Fax:
Practice Address - Street 1:52 CHRISTIAN RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-3210
Practice Address - Country:US
Practice Address - Phone:207-922-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC7299101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional