Basic Information
| Provider Information | |||||||||
| NPI: | 1467828657 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODS | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | M.A, PLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 S VIENNA ST | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712705829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182555020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3501 PATRICK ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372632153 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2015 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6384 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 600720479 | 05 | LA | MEDICAID |