Provider Demographics
NPI:1053560482
Name:WOODWARD, MARY MARSHALL (LICAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARSHALL
Last Name:WOODWARD
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:M.
Other - Middle Name:MARSHALL
Other - Last Name:WOODWARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICAC
Mailing Address - Street 1:208 VAUGHAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3204
Mailing Address - Country:US
Mailing Address - Phone:207-874-4058
Mailing Address - Fax:
Practice Address - Street 1:208 VAUGHAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3204
Practice Address - Country:US
Practice Address - Phone:207-874-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC207171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist