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General NPI Number Information
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NPI Number | 1184993297
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Entity Type | Organization
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Legal Business Name | TRACIE B GOODSPEED, LLC
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Dates
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Enumeration Date | 12/19/2011
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Last Update Date | 12/19/2011
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Provider Practice Location Address
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Address Line | 3941 S 1ST ST W
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City | MUSKOGEE
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State | OK
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Zip | 74401-8915
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Country | US
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Telephone | 918-687-3730
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Fax |
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Provider Business Mailing Address
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Address Line | 3941 S 1ST ST W
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City | MUSKOGEE
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State | OK
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Zip | 74401-8915
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Country | US
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Telephone | 918-687-3730
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TRACIE B GOODSPEED
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Credential | M.ED., LPC
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Telephone | 918-687-3730
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4461
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License Number State | OK
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