Healthcare Provider Details

I. General information

NPI: 1770962623
Provider Name (Legal Business Name): CYNTHIA Y GOODIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 APPLE BLOSSOM LN
ARLINGTON TX
76014-2614
US

IV. Provider business mailing address

3104 APPLEBLOSSOM LN
ARLINGTON TX
76014
US

V. Phone/Fax

Practice location:
  • Phone: 469-471-8604
  • Fax:
Mailing address:
  • Phone: 469-471-8604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA YVETTE GOODIE
Title or Position: OWNER
Credential:
Phone: 469-471-8604