Healthcare Provider Details

I. General information

NPI: 1598300725
Provider Name (Legal Business Name): TAHLUA NICOLE GOOSBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 VICTOR ST APT C104
BAKERSFIELD CA
93308-7001
US

IV. Provider business mailing address

PO BOX 1000
BAKERSFIELD CA
93302-1000
US

V. Phone/Fax

Practice location:
  • Phone: 661-488-5006
  • Fax:
Mailing address:
  • Phone: 661-326-2244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW92854
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW92854
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW92854
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW128718
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: