Healthcare Provider Details

I. General information

NPI: 1467668889
Provider Name (Legal Business Name): TONY GOUDY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RT 4 & 20 SOUTH 2ND FLOOR
ROCK CAVE WV
26234
US

IV. Provider business mailing address

PO BOX 129
BUCKHANNON WV
26201-0129
US

V. Phone/Fax

Practice location:
  • Phone: 304-924-9081
  • Fax:
Mailing address:
  • Phone: 304-473-8988
  • Fax: 304-472-9849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number671
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: