Healthcare Provider Details

I. General information

NPI: 1205425758
Provider Name (Legal Business Name): KELSEY RAE GOODNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date: 10/20/2024
Reactivation Date: 11/22/2024

III. Provider practice location address

4350 E MUIRWOOD DR STE 130
PHOENIX AZ
85048-8807
US

IV. Provider business mailing address

1546 N PARKWAY DR
GILBERT AZ
85234-5412
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-6981
  • Fax: 480-898-7419
Mailing address:
  • Phone: 480-716-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBEH-001413
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: