Basic Information
| Provider Information | |||||||||
| NPI: | 1770052417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODRUM | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GINTHER | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | LEA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6350 W ANDREW JOHNSON HWY | ||||||||
| Address2: | |||||||||
| City: | TALBOTT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378778605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553565 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 E WATT ST | ||||||||
| Address2: | |||||||||
| City: | ALCOA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377012236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731616 | ||||||||
| FaxNumber: | 8652731645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2018 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103T00000X | P3692 | TN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.