Healthcare Provider Details

I. General information

NPI: 1073009130
Provider Name (Legal Business Name): BETHANI J GOODRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 05/15/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2344 HELEN ST N
NORTH SAINT PAUL MN
55109-2942
US

IV. Provider business mailing address

14301 EWING AVE S
BURNSVILLE MN
55306-4885
US

V. Phone/Fax

Practice location:
  • Phone: 952-746-5350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: