Provider Demographics
NPI:1174088660
Name:WOODSON, CORY (RAC)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:WOODSON
Suffix:
Gender:M
Credentials:RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13675 COURSEY BLVD APT 231
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1347
Mailing Address - Country:US
Mailing Address - Phone:318-664-6395
Mailing Address - Fax:
Practice Address - Street 1:13675 COURSEY BLVD APT 231
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1347
Practice Address - Country:US
Practice Address - Phone:318-664-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1632101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)