Provider Demographics
NPI:1861738767
Name:STALLWORTH-WOODARD, ANTOINETTE (LMFT)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:STALLWORTH-WOODARD
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANTOINETTE RUCKER
Mailing Address - Street 1:24077 STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-8519
Mailing Address - Country:US
Mailing Address - Phone:530-265-9057
Mailing Address - Fax:
Practice Address - Street 1:1848 WILLOW PASS RD STE 115
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2591
Practice Address - Country:US
Practice Address - Phone:916-362-8292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT106371106H00000X
CAIMF 73644106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist