Active NPI
Dina Breanne Maxine Woodworth
- Behavior Analyst
- O Fallon, IL
National Provider Identifier
1053955906
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Behavior Analyst
- License
- W363-1629-3972
- Practice address
- 634 N Main St
O Fallon, IL 62269-3751 - Phone
- (618) 726-0701
- Fax
- (224) 210-1514
- NPI assigned
- Nov 4, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Behavior Analyst | 103K00000X | W363-1629-3972 | IL | Primary |
Addresses
Primary practice location
634 N Main St
O Fallon, IL 62269-3751
Mailing address
2222 Rockwood Dr
Belleville, IL 62221-6839
Phone (815) 383-4381
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| W363-1629-3972 | IL | MD | Behavioral Analyst |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1572825600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1572825600000",
"number": "1053955906",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2222 ROCKWOOD DR",
"city": "BELLEVILLE",
"state": "IL",
"postal_code": "622216839",
"telephone_number": "815-383-4381"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "634 N MAIN ST",
"city": "O FALLON",
"state": "IL",
"postal_code": "622693751",
"telephone_number": "618-726-0701",
"fax_number": "224-210-1514"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WOODWORTH",
"first_name": "DINA",
"middle_name": "BREANNE MAXINE",
"name_prefix": "Miss",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-11-04",
"last_updated": "2019-11-04",
"status": "A"
},
"taxonomies": [
{
"code": "103K00000X",
"taxonomy_group": "",
"desc": "Behavior Analyst",
"state": "IL",
"license": "W363-1629-3972",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in O Fallon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 4, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.