Healthcare Provider Details

I. General information

NPI: 1700619954
Provider Name (Legal Business Name): DESIREE Y GOODE-GREEN MS, CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 FAIRMOUNT AVE STE 200-T47
TOWSON MD
21286-2624
US

IV. Provider business mailing address

849 FAIRMOUNT AVE STE 200-T47
TOWSON MD
21286-2624
US

V. Phone/Fax

Practice location:
  • Phone: 443-360-5161
  • Fax:
Mailing address:
  • Phone: 443-360-5161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number164.011505
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number164.011505
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberNU200000269
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberNU200000269
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDX6809
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDN-0011272
License Number StateDE
# 7
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDN-0011272
License Number StateDE
# 8
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDN009060
License Number StatePA
# 9
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX6809
License Number StateMD
# 10
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDN009060
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: