Provider Demographics
NPI:1861103392
Name:WOODSON, LASTARR
Entity type:Individual
Prefix:
First Name:LASTARR
Middle Name:
Last Name:WOODSON
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 1:313 E BROAD ST STE 42
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-1737
Mailing Address - Country:US
Mailing Address - Phone:804-475-8324
Mailing Address - Fax:
Practice Address - Street 1:313 E BROAD ST STE 42
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1737
Practice Address - Country:US
Practice Address - Phone:804-475-8324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5249101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA87-4321733Medicaid