=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609650480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRAKEL GRACE MAYORAL-GOODWIN LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2023
-----------------------------------------------------
Last Update Date | 08/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5959 WEST LOOP S STE 430
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77401-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-0776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11110 BRAEWICK DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77096-5819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-902-6715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 109069
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------