Healthcare Provider Details

I. General information

NPI: 1942763644
Provider Name (Legal Business Name): CASEY NICHOLE GOODE SCHOOL PSYCHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 JACKSON PL
HONOLULU HI
96819-1507
US

IV. Provider business mailing address

46 JACKSON PL
HONOLULU HI
96819-1507
US

V. Phone/Fax

Practice location:
  • Phone: 254-482-2999
  • Fax:
Mailing address:
  • Phone: 254-482-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberCKG-0108-7506
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number34740
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: