Healthcare Provider Details

I. General information

NPI: 1023884384
Provider Name (Legal Business Name): SHELLEY I GOAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 BLUEBERRY HILL RD
EL PRADO NM
87529-7305
US

IV. Provider business mailing address

259 BLUEBERRY HILL RD
EL PRADO NM
87529-7305
US

V. Phone/Fax

Practice location:
  • Phone: 214-622-7543
  • Fax:
Mailing address:
  • Phone: 214-622-7543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0224081
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: