1417017112 NPI number — MRS. MICHELLE ANN GOODER OTR

Table of content: MRS. MICHELLE ANN GOODER OTR (NPI 1417017112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417017112 NPI number — MRS. MICHELLE ANN GOODER OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODER
Provider First Name:
MICHELLE
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417017112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
812 HIGHLANDER TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54016-7977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-386-1685
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 N LOCKWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54028-9710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-698-2451
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2006

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: 225X00000X , with the licence number:  4063026 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40880200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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