=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144567348
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA M GOODIN M.A., L.P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2013
-----------------------------------------------------
Last Update Date | 01/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3909 S WILSON RD
-----------------------------------------------------
City | RADCLIFF
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40160-8944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-351-9444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3909 S WILSON RD
-----------------------------------------------------
City | RADCLIFF
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40160-8944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-351-9444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1011
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------