Healthcare Provider Details

I. General information

NPI: 1184993297
Provider Name (Legal Business Name): TRACIE B GOODSPEED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3941 S 1ST ST W
MUSKOGEE OK
74401-8915
US

IV. Provider business mailing address

3941 S 1ST ST W
MUSKOGEE OK
74401-8915
US

V. Phone/Fax

Practice location:
  • Phone: 918-687-3730
  • Fax:
Mailing address:
  • Phone: 918-687-3730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4461
License Number StateOK

VIII. Authorized Official

Name: TRACIE B GOODSPEED
Title or Position: OWNER
Credential: M.ED., LPC
Phone: 918-687-3730