Individual
MISS DINA BREANNE MAXINE WOODWORTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
634 N MAIN ST, O FALLON, IL 62269-3751
(618) 726-0701
(224) 210-1514
Mailing address
2222 ROCKWOOD DR, BELLEVILLE, IL 62221-6839
(815) 383-4381
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
W363-1629-3972
IL
Other
Enumeration date
11/04/2019
Last updated
11/04/2019
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