Provider Demographics
NPI:1730703380
Name:WOODY, LYDIA RUTHANN
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:RUTHANN
Last Name:WOODY
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 1:931 CHEVY WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:745 N ROSE ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535-5704
Practice Address - Country:US
Practice Address - Phone:541-535-6329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORR6684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor