Provider Demographics
NPI:1174740252
Name:WOODIN, MICHAEL (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WOODIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:765-935-8802
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1130 N J ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1913
Practice Address - Country:US
Practice Address - Phone:765-983-3298
Practice Address - Fax:765-983-7970
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042068A103T00000X
OHP.07823103T00000X
IN20042068B103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103T00000XBehavioral Health & Social Service ProvidersPsychologist