1093741514 NPI number — JUDY G GOODSON LMSW

Table of content: JUDY G GOODSON LMSW (NPI 1093741514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093741514 NPI number — JUDY G GOODSON LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODSON
Provider First Name:
JUDY
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ENDRESS
Provider Other First Name:
JUDY
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093741514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4253 N CROSSOVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-4593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-521-5731
Provider Business Mailing Address Fax Number:
479-521-4926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10301 MAYO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARLING
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72923-1660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-494-5700
Provider Business Practice Location Address Fax Number:
479-484-8142
Provider Enumeration Date:
06/25/2006

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: 104100000X , with the licence number:  1670-M , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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