1124580436 NPI number — MRS. MERIAM THERESA GOFF MA60936473

Table of content: MRS. MERIAM THERESA GOFF MA60936473 (NPI 1124580436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124580436 NPI number — MRS. MERIAM THERESA GOFF MA60936473

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOFF
Provider First Name:
MERIAM
Provider Middle Name:
THERESA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA60936473
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOFF
Provider Other First Name:
MERIAM
Provider Other Middle Name:
THERESA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA60936473
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124580436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4731 176TH ST SW APT K8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNNWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98037-3429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-454-7226
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18927 33RD AVE W STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNNWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98036-4726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-776-1177
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2019

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: 225700000X , with the licence number:  MA60936473 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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