1235294158 NPI number — MRS. CORENE CREE MCGOODEN LCSW

Table of content: MRS. CORENE CREE MCGOODEN LCSW (NPI 1235294158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235294158 NPI number — MRS. CORENE CREE MCGOODEN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGOODEN
Provider First Name:
CORENE
Provider Middle Name:
CREE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAUSERMAN
Provider Other First Name:
CORENE
Provider Other Middle Name:
CREE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235294158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2911 ROBERTS AVE UNIT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32310-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-644-1543
Provider Business Mailing Address Fax Number:
855-230-7421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2911 ROBERTS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32310-5007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-644-1543
Provider Business Practice Location Address Fax Number:
855-230-7421
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW7061 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104202600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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