Healthcare Provider Details

I. General information

NPI: 1467646760
Provider Name (Legal Business Name): RANDALL J GOODFRIEND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S MAIN
SUPERIOR AZ
85273-0004
US

IV. Provider business mailing address

PO BOX 3160
APACHE JUNCTION AZ
85217-3160
US

V. Phone/Fax

Practice location:
  • Phone: 480-288-5328
  • Fax: 480-288-5339
Mailing address:
  • Phone: 480-288-5328
  • Fax: 480-288-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-2392
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: