Provider Demographics
NPI:1548342512
Name:WOODRUFF, LISA LOUISE (LP,LICSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:LOUISE
Last Name:WOODRUFF
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Gender:F
Credentials:LP,LICSW
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:4505 WHITE BEAR PKWY
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3678
Mailing Address - Country:US
Mailing Address - Phone:651-426-8191
Mailing Address - Fax:651-426-6766
Practice Address - Street 1:4505 WHITE BEAR PKWY
Practice Address - Street 2:SUITE 1800
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3678
Practice Address - Country:US
Practice Address - Phone:651-426-8191
Practice Address - Fax:651-426-6766
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP0870103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-06159OtherUBH