Healthcare Provider Details

I. General information

NPI: 1639244114
Provider Name (Legal Business Name): LAWRENCE A GOODING M.S. & PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 UNIVERSITY AVE SUITE #4
FAIRBANKS AK
99709-3643
US

IV. Provider business mailing address

600 UNIVERSITY AVE SUITE #4
FAIRBANKS AK
99709-3643
US

V. Phone/Fax

Practice location:
  • Phone: 907-479-8545
  • Fax: 907-474-8165
Mailing address:
  • Phone: 907-479-8545
  • Fax: 907-474-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number133
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number133
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number133
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: