Provider Demographics
NPI:1053955906
Name:WOODWORTH, DINA BREANNE MAXINE
Entity type:Individual
Prefix:MISS
First Name:DINA
Middle Name:BREANNE MAXINE
Last Name:WOODWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 ROCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-6839
Mailing Address - Country:US
Mailing Address - Phone:815-383-4381
Mailing Address - Fax:
Practice Address - Street 1:634 N MAIN ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3751
Practice Address - Country:US
Practice Address - Phone:618-726-0701
Practice Address - Fax:224-210-1514
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILW363-1629-3972103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst