MEDICARE: MRS. MARY GOODNER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	4981	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4981	OTHER	TN	LICENSED CLINICAL SOCIAL WORKER LICENSE NUMBER

General Provider Information

NPI Number	:	1598920803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY GOODNER LCSW

Provider Business Mailing Address
First Line	:	2408 W CLAY DR
Second Line	:
City	:	LEBANON
State	:	TN
Zip	:	37087-3168
Country	:	US
Telephone Number	:	615-444-2486
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 PARK AVE
Second Line	:
City	:	LEBANON
State	:	TN
Zip	:	37087-3721
Country	:	US
Telephone Number	:	615-449-0500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2008
Last Update Date	:	07/25/2008

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