Healthcare Provider Details

I. General information

NPI: 1639992597
Provider Name (Legal Business Name): KATELYN GOODALL PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEERFIELD PRESERVE BLVD
ST AUGUSTINE FL
32086-5966
US

IV. Provider business mailing address

28 WHIRLAWAY DR
PALM COAST FL
32164-7260
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-0814
  • Fax:
Mailing address:
  • Phone: 361-205-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: